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Simplified Technique of Total Aortic Arch Replacement With Minimal Circulatory and Myocardial Ischemia
Simplified Technique of Total Aortic Arch Replacement With Minimal Circulatory and Myocardial Ischemia Derek R. Brinster, MD Virginia Commonwealth University Medical Center, Medical College of Virginia Campus, Richmond, Virginia
This manuscript describes the initial experience of 15 patients undergoing aortic arch replacement using a modification of the trifurcate arch technique described by Spielvogel and coworkers [1]. This technique provides continuous antegrade cerebral perfusion and minimal myocardial ischemia with mild hypothermia. (Ann Thorac Surg 2012;94:e83–5) © 2012 by The Society of Thoracic Surgeons
S
urgical reconstruction and replacement of the thoracic aortic arch requires advanced circulatory management protocols and surgical techniques. The primary morbidity after thoracic arch reconstructions is temporary or permanent neurologic dysfunction. Arch reconstruction demands separation of the circulatory system into 3 primary circulations: cerebral, systemic, and myocardial. The technique described here provides a simple and effective means to reduce ischemia times to all 3 systems. This technique was used from 2009 to 2011 in 15 consecutive patients who required transverse aortic arch reconstruction. Age at operation ranged from 31 to 81 years, and operation was undertaken for a variety of pathologic conditions. All patients had replacement of the ascending aorta and transverse aorta and distal arch “elephant trunk” reconstruction. All patients provided informed consent for the operation.
Technique The main body of the trifurcate graft is trimmed and anastomosed to the ascending aorta graft before cardiopulmonary bypass. The cardiopulmonary circuit is constructed to form a Y at the arterial inflow with 1 limb with a 0.375- to 0.25-inch adapter that is tied into the most distal limb of the trifurcate graft. The patient is placed on cardiopulmonary bypass and cooled to approximately 28°C. During cooling, the aortic arch is sequentially Accepted for publication May 11, 2012. Address correspondence to Dr Brinster, Divisions of Cardiothoracic and Vascular Surgery, Virginia Commonwealth University Medical Center, Medical College of Virginia Campus, West Hospital Bld, 7th Flr, South Wing, 1200 E Broad St, PO Box 980068, Richmond VA 23298-0068; e-mail: [email protected].
© 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
transected and anastomosed to the trifurcate graft with continuous perfusion through the graft (Fig 1A). Therefore there is no period of cerebral circulatory arrest because either the innominate artery or the left carotid artery, or both, are being perfused through the graft arterial inflow. Typically, by the time the innominate artery and the left common carotid artery have been anastomosed to the trifurcate graft, the patient’s temperature is approximately 28°C. The cross-clamp is then applied to the ascending aorta with the handle pointed caudad to allow antegrade cardioplegia during the elephant trunk anastomosis. A standard elephant trunk anastomosis is performed with the graft brought forward and recannulated to allow systemic arterial perfusion (Fig 1B). The ascending aorta is replaced with the graft, with the side arm fashioned before cardiopulmonary bypass, and anastomosed to the elephant trunk graft, with subsequent termination of myocardial ischemia time (Fig 1C). With resumption of myocardial rhythm, the proximal main body of the trifurcate graft is anastomosed to the side arm of the ascending aorta graft (Fig 1C). Systemic and cerebral flows are united (Fig 1D). The arterial limb of the trifurcate graft is now trimmed or fashioned for anastomosis to the left subclavian artery, which is performed during weaning the patient from cardiopulmonary bypass or off bypass. The mean duration of cardiopulmonary bypass and aortic cross-clamp time for isolated aortic procedures was 138 ⫾ 15 minutes and 34 ⫾ 4 minutes, respectively. Average time for completion of the innominate artery and the carotid artery anastomosis was 9 ⫾ 0.1 minutes. Adjunctive neuroprotective strategies included ice packs on the head, alpha-stat management, and routine hemoglobin management of ⬎ 5.0 g/dL, but no pharmacologic manipulation. Average length of stay (LOS) was 13 ⫾ 5 days with no mortalities and no neurologic or bleeding complications. On review of the LOS, 3 outlier patients with the longest LOS had unique circumstances: 1 patient required tracheotomy for respiratory failure attributable to severe obesity (body mass index ⬎ 48) and 2 patients were outliers for psychological/social reasons. Systemic end-organ protection was assessed by renal function after operation. No patients required permanent 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2012.05.094
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HOW TO DO IT BRINSTER SIMPLIFIED TOTAL AORTIC ARCH REPLACEMENT
Ann Thorac Surg 2012;94:e83–5
Fig 1. (A) Sequential anastomosis and debranching of the brachiocephalic vessels with continues cerebral perfusion (arrow indicates arterial inflow). (B) Cross-clamping of ascending aorta with continuous antegrade cardioplegia and distal arch reconstruction (arrow indicates arterial inflow). (C) Connection of ascending aorta graft to arch graft and resumption of myocardial perfusion, with anastomosis of arch graft to ascending aorta. (D) Systemic and cerebral flows are united.
or transient dialysis. Two patients (13%) did have a transient decrease in estimated glomerular filtration rate (eGFR) postoperatively to ⬍ 40 mL/min/m2 but ⬎ 20 mL/min/m2. One of those patients had chronic kidney disease preoperatively with an eGFR of 58 mL/min/m2, and both patients’ eGFR returned to baseline by time of discharge.
Comment Circulatory management in aortic arch reconstruction continues to evolve. Current management techniques include hypothermic circulatory arrest alone, hypothermic circulatory arrest in conjunction with retrograde cerebral perfusion or antegrade cerebral perfusion, moderate hypothermia with antegrade cerebral perfusion, and even normothermic complete arch replacement without circulatory arrest. Several studies have demonstrated the safety and efficacy of these various approaches. However, recent evidence supports the use of moderate hypothermia, with a lower
risk of reexploration for bleeding with no adverse effect on morbidity and mortality [2]. In addition, the use of bilateral antegrade cerebral perfusion instead of selective unilateral antegrade cerebral perfusion maintains more uniform cerebral perfusion and reduces brain ischemia [3]. Transient or permanent neurologic deficits remain the major cause of morbidity and mortality after complex aortic arch reconstruction. This described technique offers several advantages to simplify the procedure and reduce ischemic time. This method allows continuous cerebral perfusion to decrease neurologic complications. In addition, the use of moderate hypothermia decreases cardiopulmonary bypass time and cold coagulopathy. Finally, myocardial ischemia time is dramatically reduced by performing the arch reconstruction without cross-clamping by clamping the ascending aorta to allow continuous antegrade perfusion during distal aortic arch reconstruction and using a side arm graft on the ascending aorta graft to allow
Ann Thorac Surg 2012;94:e83–5
connection of the trifurcate graft to the ascending aorta without myocardial ischemia. In my opinion, the use of mild hypothermia and the separation of the circulation into 3 circulatory systems with the applied technique permits reduced ischemia time for all major systems and decreased duration of surgical reconstruction. Illustrative support was provided by Vascutek, Terumo, Renfrewshire, Scotland, UK.
HOW TO DO IT BRINSTER SIMPLIFIED TOTAL AORTIC ARCH REPLACEMENT
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References 1. Spielvogel D, Mathur MN, Lansman SL, Griepp RB. Aortic arch reconstruction using a trifurcated graft. Ann Thorac Surg 2003;75:1034 – 6. 2. Kamiya H, Hagl C, Kropivnitskaya I, et al. The safety of moderate hypothermic lower body circulatory arrest with selective cerebral perfusion: a propensity score analysis. J Thorac Cardiovasc Surg 2007;133:501–9. 3. Harrer M, Waldenberger FR, Weiss G, et al. Aortic arch surgery using bilateral antegrade selective cerebral perfusion in combination with near-infrared spectroscopy. Eur J Cardiothorac Surg 2010;38:561–7.
This manuscript describes the initial experience of 15 patients undergoing aortic arch replacement using a modification of the trifurcate arch technique described by Spielvogel and coworkers [1]. This technique provides continuous antegrade cerebral perfusion and minimal myocardial ischemia with mild hypothermia. (Ann Thorac Surg 2012;94:e83–5) © 2012 by The Society of Thoracic Surgeons
S
urgical reconstruction and replacement of the thoracic aortic arch requires advanced circulatory management protocols and surgical techniques. The primary morbidity after thoracic arch reconstructions is temporary or permanent neurologic dysfunction. Arch reconstruction demands separation of the circulatory system into 3 primary circulations: cerebral, systemic, and myocardial. The technique described here provides a simple and effective means to reduce ischemia times to all 3 systems. This technique was used from 2009 to 2011 in 15 consecutive patients who required transverse aortic arch reconstruction. Age at operation ranged from 31 to 81 years, and operation was undertaken for a variety of pathologic conditions. All patients had replacement of the ascending aorta and transverse aorta and distal arch “elephant trunk” reconstruction. All patients provided informed consent for the operation.
Technique The main body of the trifurcate graft is trimmed and anastomosed to the ascending aorta graft before cardiopulmonary bypass. The cardiopulmonary circuit is constructed to form a Y at the arterial inflow with 1 limb with a 0.375- to 0.25-inch adapter that is tied into the most distal limb of the trifurcate graft. The patient is placed on cardiopulmonary bypass and cooled to approximately 28°C. During cooling, the aortic arch is sequentially Accepted for publication May 11, 2012. Address correspondence to Dr Brinster, Divisions of Cardiothoracic and Vascular Surgery, Virginia Commonwealth University Medical Center, Medical College of Virginia Campus, West Hospital Bld, 7th Flr, South Wing, 1200 E Broad St, PO Box 980068, Richmond VA 23298-0068; e-mail: [email protected].
© 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
transected and anastomosed to the trifurcate graft with continuous perfusion through the graft (Fig 1A). Therefore there is no period of cerebral circulatory arrest because either the innominate artery or the left carotid artery, or both, are being perfused through the graft arterial inflow. Typically, by the time the innominate artery and the left common carotid artery have been anastomosed to the trifurcate graft, the patient’s temperature is approximately 28°C. The cross-clamp is then applied to the ascending aorta with the handle pointed caudad to allow antegrade cardioplegia during the elephant trunk anastomosis. A standard elephant trunk anastomosis is performed with the graft brought forward and recannulated to allow systemic arterial perfusion (Fig 1B). The ascending aorta is replaced with the graft, with the side arm fashioned before cardiopulmonary bypass, and anastomosed to the elephant trunk graft, with subsequent termination of myocardial ischemia time (Fig 1C). With resumption of myocardial rhythm, the proximal main body of the trifurcate graft is anastomosed to the side arm of the ascending aorta graft (Fig 1C). Systemic and cerebral flows are united (Fig 1D). The arterial limb of the trifurcate graft is now trimmed or fashioned for anastomosis to the left subclavian artery, which is performed during weaning the patient from cardiopulmonary bypass or off bypass. The mean duration of cardiopulmonary bypass and aortic cross-clamp time for isolated aortic procedures was 138 ⫾ 15 minutes and 34 ⫾ 4 minutes, respectively. Average time for completion of the innominate artery and the carotid artery anastomosis was 9 ⫾ 0.1 minutes. Adjunctive neuroprotective strategies included ice packs on the head, alpha-stat management, and routine hemoglobin management of ⬎ 5.0 g/dL, but no pharmacologic manipulation. Average length of stay (LOS) was 13 ⫾ 5 days with no mortalities and no neurologic or bleeding complications. On review of the LOS, 3 outlier patients with the longest LOS had unique circumstances: 1 patient required tracheotomy for respiratory failure attributable to severe obesity (body mass index ⬎ 48) and 2 patients were outliers for psychological/social reasons. Systemic end-organ protection was assessed by renal function after operation. No patients required permanent 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2012.05.094
e84
HOW TO DO IT BRINSTER SIMPLIFIED TOTAL AORTIC ARCH REPLACEMENT
Ann Thorac Surg 2012;94:e83–5
Fig 1. (A) Sequential anastomosis and debranching of the brachiocephalic vessels with continues cerebral perfusion (arrow indicates arterial inflow). (B) Cross-clamping of ascending aorta with continuous antegrade cardioplegia and distal arch reconstruction (arrow indicates arterial inflow). (C) Connection of ascending aorta graft to arch graft and resumption of myocardial perfusion, with anastomosis of arch graft to ascending aorta. (D) Systemic and cerebral flows are united.
or transient dialysis. Two patients (13%) did have a transient decrease in estimated glomerular filtration rate (eGFR) postoperatively to ⬍ 40 mL/min/m2 but ⬎ 20 mL/min/m2. One of those patients had chronic kidney disease preoperatively with an eGFR of 58 mL/min/m2, and both patients’ eGFR returned to baseline by time of discharge.
Comment Circulatory management in aortic arch reconstruction continues to evolve. Current management techniques include hypothermic circulatory arrest alone, hypothermic circulatory arrest in conjunction with retrograde cerebral perfusion or antegrade cerebral perfusion, moderate hypothermia with antegrade cerebral perfusion, and even normothermic complete arch replacement without circulatory arrest. Several studies have demonstrated the safety and efficacy of these various approaches. However, recent evidence supports the use of moderate hypothermia, with a lower
risk of reexploration for bleeding with no adverse effect on morbidity and mortality [2]. In addition, the use of bilateral antegrade cerebral perfusion instead of selective unilateral antegrade cerebral perfusion maintains more uniform cerebral perfusion and reduces brain ischemia [3]. Transient or permanent neurologic deficits remain the major cause of morbidity and mortality after complex aortic arch reconstruction. This described technique offers several advantages to simplify the procedure and reduce ischemic time. This method allows continuous cerebral perfusion to decrease neurologic complications. In addition, the use of moderate hypothermia decreases cardiopulmonary bypass time and cold coagulopathy. Finally, myocardial ischemia time is dramatically reduced by performing the arch reconstruction without cross-clamping by clamping the ascending aorta to allow continuous antegrade perfusion during distal aortic arch reconstruction and using a side arm graft on the ascending aorta graft to allow
Ann Thorac Surg 2012;94:e83–5
connection of the trifurcate graft to the ascending aorta without myocardial ischemia. In my opinion, the use of mild hypothermia and the separation of the circulation into 3 circulatory systems with the applied technique permits reduced ischemia time for all major systems and decreased duration of surgical reconstruction. Illustrative support was provided by Vascutek, Terumo, Renfrewshire, Scotland, UK.
HOW TO DO IT BRINSTER SIMPLIFIED TOTAL AORTIC ARCH REPLACEMENT
e85
References 1. Spielvogel D, Mathur MN, Lansman SL, Griepp RB. Aortic arch reconstruction using a trifurcated graft. Ann Thorac Surg 2003;75:1034 – 6. 2. Kamiya H, Hagl C, Kropivnitskaya I, et al. The safety of moderate hypothermic lower body circulatory arrest with selective cerebral perfusion: a propensity score analysis. J Thorac Cardiovasc Surg 2007;133:501–9. 3. Harrer M, Waldenberger FR, Weiss G, et al. Aortic arch surgery using bilateral antegrade selective cerebral perfusion in combination with near-infrared spectroscopy. Eur J Cardiothorac Surg 2010;38:561–7.