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Replacement of the Descending Thoracic Aorta: Contemporary Outcomes Using Hypothermic Circulatory Arrest
Alexander Kulik, Catherine F Castner, Nicholas T Kouchoukos
Missouri Baptist Medical Center, St. Louis, MO
Background: Recent advances in endovascular repair of the descending thoracic aorta (DTA) have put into question the role of open surgery. We evaluated our experience with open DTA replacement using cardiopulmonary bypass (CPB) and hypothermic circulatory arrest (HCA). This technique enables concurrent repair of the distal aortic arch, maintenance of left subclavian artery patency, and provides protection against spinal cord ischemic injury (SCII).
Methods: From May 1989 to August 2008, 151 patients underwent DTA replacement with left thoracotomy, CPB and HCA. The mean age of the patients was 62±15 years (range 20-85). There were 47 females (31%). Ten patients had Marfan syndrome (7%). The treated diseases included: aneurysm 89 (59%), chronic type B dissection 25 (17%), acute type B dissection 7 (5%), and aortic coarctation 11 (7%). Seventeen patients (11%) underwent emergent operation. The extent of repair was: distal arch and proximal DTA 58 (38%), distal arch and entire DTA 13 (9%), proximal DTA 28 (19%), distal DTA 17 (11%), and entire DTA 35 (23%).
Results: The mean durations of CPB and HCA were 107±34 and 32±9 minutes, respectively. Stroke occurred in five patients (3%), SCII in 2 patients (1%; 1 paraplegia, 1 paraparesis), and renal failure requiring dialysis in 2 patients (1%). Thirty-day and six-month mortality rates were 4% and 10%, respectively. Following emergent operation, the thirty-day mortality rate was 18% compared to 2% after elective surgery (P=0.02). Ventilatory support was required for a mean of 3±10 days (median, 1 day), and the duration of intensive care unit stay was 6±9 days (median, 4 days). Hospital length of stay was 16±15 days (median, 11 days). During the follow-up period that extended to 18 years, there were 35 late deaths. Five- and ten-year survival rates were 71% and 45%, respectively. Five patients required reoperation on the graft or contiguous aorta at a mean of 5±4 years after the initial repair. Five- and ten-year actuarial rates of freedom from reoperation were 96% and 92%, respectively.
Conclusions: Cardiopulmonary bypass with HCA can be safely used in the replacement of the DTA and the distal aortic arch. While more invasive than endovascular stent graft placement, this open surgical technique provides definitive repair, maintenance of left subclavian artery patency, a low incidence of reoperation, and acceptable mortality and morbidity rates that do not exceed those reported for endovascular repair.
Table - Extent of Repair and Associated Morbidity and Mortality | | | | | | | Extent of Repair | Number of Patients | 30-day Mortality | Stroke | Spinal Cord Ischemic Injury | Dialysis | | Proximal DTA with Distal Arch | 58 | 1 | 4 | 0 | 1 | | Proximal DTA without Distal Arch | 28 | 0 | 1 | 0 | 0 | | Entire DTA with Distal Arch | 13 | 1 | 0 | 1 | 0 | | Entire DTA without Distal Arch | 35 | 3 | 0 | 1 | 1 | | Distal DTA | 17 | 1 | 0 | 0 | 0 | | Total | 151 | 6 (4%) | 5 (3%) | 2 (1%) | 2 (1%) |
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