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13.2 Type A acute aortic dissection: Experience with 104 patients
Wednesday, 24 September 1997
0800-1200
Session 13-Thoracic Aorta Co-Chairmen: C.P.Young, A. Furuse Elizabeth W indsor
13.1 Surgical Treatment of Aortic Arch Aneurysm-Adjunctive Method and Operative Results
S. KOZAWA, T. ASADA, N. MUKOHARA, T. HIGAMI, H. OBO, K. GAN, K. IWAHASHI, H. NOHARA and K. OGAWA, Himeji, Hyogo, Japan Brain protection during the surgical procedure for an aortic arch aneurysm is one of the most important factors to succeed in the operation. Patients and Methods: From October 1990 to August 1996, 95 patients underwent surgical treatment for aortic arch aneurysms. According to the adjunctive methods used during operation, the patients were divided into two groups. Group 1 consisted of 54 patients who had a selective cerebral perfusion (SCP). Group 2 consisted of 41 patients who underwent retrograde cerebral perfusion during hypothermic circulatory arrest (RCP). We studied the changes of cerebrovascular oxygen saturation (rSOz) to evaluate the effect of SCP and RCP in 33 patients (15 SCP, 18 RCP) with aortic arch reconstruction during the procedure. The rSOz was monitored with a spectroscopy instrument (Invos 3100, Somanetics). Results: The actuarial probability of survival (including operative deaths) was 85% in group 1,90% in group 2 at 1 month, and 75% in group 1, 78% in group 2 at 33 months, respectively. There is no statistical difference of in survival rates between the two groups. Although RCP time with a mean of 36 min was statistically shorter than SCP time (101 min), the mean value of rSOz during brain protection in the RCP group was decreased from 77 to 62%. In contrast, the mean value of rSOz in the SCP group was well maintained from 79 to 75%. We conclude that with regard to brain protection assessed from rS02 measured by an Invos 3100 cerebral oximeter there is no time limitation of SCP during the procedure but RCP had a limit on the duration.
13.2 Type A Acute Aortic Dissection: Experience with 104 Patients
VC. DOISY, A. PRAT, A. VINCENTELLI, M.A. VASSEUR; EP. DEVULDER, H. BAUDSON and C. STANK0 WIAK, Lille, France Background: From November 1979 to December 1996, 104 patients underwent surgical treatment of acute type A aortic dissection. Standard operative technique included aortic valve resuspension with GRF glue, prosthetic replacement of the ascending aorta. In the case of annulo-aortic ectasia (n = 18), we performed composite graft replacement. Resuspension of
66
the aortic valve was used in all other cases. Uncommon techniques were: primary repair of dissection with surgical glue (n = 4) and intraluminal prosthesis (n = 2). Materials and methods: From 1979 to 1992 (Group A, n = 74) distal anastomosis was usually performed with the aorta crossclamped. Since 1993 (Group B, n = 30) open distal anastomosis was performed in most patients, in some cases (tt = 14) with complete aortic arch replacement. In this group cerebral protection was achieved by selective antegrade cerebral perfusion. Results: Overall mortality was 25% (group A, 31%:, group B, 10%). The mean follow-up was 72.1 months (2-204 months). Eight patients required late reoperation: aortic valve replacement (n = 2), arch replacement (n = 2), elephant trunk procedure (n = 3), Bentall procedure (n = 2) and thoracoabdominal aorta replacement (n = 3). Conclusions: On the basis of this study it is suggested that: Resection of the initial intimal tear is essential; Open distal anastomosis should be used routinely and is safe with cerebral protection by selective antegrade cerebral perfusion; Intra-operative bleeding from suture lines has nearly disappeared with the use of surgical glue; Good short and long term results can be achieved with ascending aorta grafting and valve resuspension in most cases.
13.3 Composite Graft Repair of Ascending Aorta: Evaluation with Enhanced MRI
R. FATTORI, B. DESCOVZCH, P. BERTACCINI, E CELLE77’1, I. CALDARERA, E. NEGRINI and A. PIERANGELZ, Bologna, Italy Composite graft replacement of the ascending aorta as the Bentall technique, or its modifications, may have a relatively high incidence of early and late leakage with possible false aneurysm formation. Considering that they detour asymptomatic, a scheduled monitoring is requested for their detection. Thirty-nine patients underwent MR follow-up (0.5-200 months) after composite graft replacement of the ascending aorta (19 for dissection, 20 for aneurysm). Normal postoperative perigraft findings (perigraft thickening less than 10 mm) was observed in 31 patients. Eight patients showed the presence of a periprosthetic thickening ranging from 15 to 52 mm. In order to differentiate bleeding from infection and/or reactive tissue, MRI was repeated after injection of paramagnetic contrast media. In four patients gadolinium enhanced MRI demonstrated a signal enhancement of the periprosthetic collection, high-
CARDIOVASCULAR SURGERY SEPTEMBER 1997
0800-1200
Session 13-Thoracic Aorta Co-Chairmen: C.P.Young, A. Furuse Elizabeth W indsor
13.1 Surgical Treatment of Aortic Arch Aneurysm-Adjunctive Method and Operative Results
S. KOZAWA, T. ASADA, N. MUKOHARA, T. HIGAMI, H. OBO, K. GAN, K. IWAHASHI, H. NOHARA and K. OGAWA, Himeji, Hyogo, Japan Brain protection during the surgical procedure for an aortic arch aneurysm is one of the most important factors to succeed in the operation. Patients and Methods: From October 1990 to August 1996, 95 patients underwent surgical treatment for aortic arch aneurysms. According to the adjunctive methods used during operation, the patients were divided into two groups. Group 1 consisted of 54 patients who had a selective cerebral perfusion (SCP). Group 2 consisted of 41 patients who underwent retrograde cerebral perfusion during hypothermic circulatory arrest (RCP). We studied the changes of cerebrovascular oxygen saturation (rSOz) to evaluate the effect of SCP and RCP in 33 patients (15 SCP, 18 RCP) with aortic arch reconstruction during the procedure. The rSOz was monitored with a spectroscopy instrument (Invos 3100, Somanetics). Results: The actuarial probability of survival (including operative deaths) was 85% in group 1,90% in group 2 at 1 month, and 75% in group 1, 78% in group 2 at 33 months, respectively. There is no statistical difference of in survival rates between the two groups. Although RCP time with a mean of 36 min was statistically shorter than SCP time (101 min), the mean value of rSOz during brain protection in the RCP group was decreased from 77 to 62%. In contrast, the mean value of rSOz in the SCP group was well maintained from 79 to 75%. We conclude that with regard to brain protection assessed from rS02 measured by an Invos 3100 cerebral oximeter there is no time limitation of SCP during the procedure but RCP had a limit on the duration.
13.2 Type A Acute Aortic Dissection: Experience with 104 Patients
VC. DOISY, A. PRAT, A. VINCENTELLI, M.A. VASSEUR; EP. DEVULDER, H. BAUDSON and C. STANK0 WIAK, Lille, France Background: From November 1979 to December 1996, 104 patients underwent surgical treatment of acute type A aortic dissection. Standard operative technique included aortic valve resuspension with GRF glue, prosthetic replacement of the ascending aorta. In the case of annulo-aortic ectasia (n = 18), we performed composite graft replacement. Resuspension of
66
the aortic valve was used in all other cases. Uncommon techniques were: primary repair of dissection with surgical glue (n = 4) and intraluminal prosthesis (n = 2). Materials and methods: From 1979 to 1992 (Group A, n = 74) distal anastomosis was usually performed with the aorta crossclamped. Since 1993 (Group B, n = 30) open distal anastomosis was performed in most patients, in some cases (tt = 14) with complete aortic arch replacement. In this group cerebral protection was achieved by selective antegrade cerebral perfusion. Results: Overall mortality was 25% (group A, 31%:, group B, 10%). The mean follow-up was 72.1 months (2-204 months). Eight patients required late reoperation: aortic valve replacement (n = 2), arch replacement (n = 2), elephant trunk procedure (n = 3), Bentall procedure (n = 2) and thoracoabdominal aorta replacement (n = 3). Conclusions: On the basis of this study it is suggested that: Resection of the initial intimal tear is essential; Open distal anastomosis should be used routinely and is safe with cerebral protection by selective antegrade cerebral perfusion; Intra-operative bleeding from suture lines has nearly disappeared with the use of surgical glue; Good short and long term results can be achieved with ascending aorta grafting and valve resuspension in most cases.
13.3 Composite Graft Repair of Ascending Aorta: Evaluation with Enhanced MRI
R. FATTORI, B. DESCOVZCH, P. BERTACCINI, E CELLE77’1, I. CALDARERA, E. NEGRINI and A. PIERANGELZ, Bologna, Italy Composite graft replacement of the ascending aorta as the Bentall technique, or its modifications, may have a relatively high incidence of early and late leakage with possible false aneurysm formation. Considering that they detour asymptomatic, a scheduled monitoring is requested for their detection. Thirty-nine patients underwent MR follow-up (0.5-200 months) after composite graft replacement of the ascending aorta (19 for dissection, 20 for aneurysm). Normal postoperative perigraft findings (perigraft thickening less than 10 mm) was observed in 31 patients. Eight patients showed the presence of a periprosthetic thickening ranging from 15 to 52 mm. In order to differentiate bleeding from infection and/or reactive tissue, MRI was repeated after injection of paramagnetic contrast media. In four patients gadolinium enhanced MRI demonstrated a signal enhancement of the periprosthetic collection, high-
CARDIOVASCULAR SURGERY SEPTEMBER 1997