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Received 2 November 2004; revised 24 January 2005; Accepted 25 January 2005. Available online 23 March 2005.
Abstract
Objective: From 1998, we have adopted the arch first technique (reconstruction of arch vessels first and distal anastomosis second) instead of the distal anastomosis first technique for total arch replacement. The aim is to reduce the period of deep hypothermic circulatory arrest and the retrograde cerebral
perfusion
time. We evaluate the surgical results of the arch first technique. Methods: The arch first technique was used in 50 cases (38 male and 12 female), of average age 68 years, from 1998 to 2003. There were 33 true aneurysms and 10 chronic and seven acute type A dissections. Clinical results were evaluated and compared with the distal first technique used in 24 cases operated on between 1992 and 1998. These were 14 males and 10 females, with an average age of 68 years. There were 16 true aneurysms, and three chronic and five acute aortic dissections. Results: For the arch first technique there is a significantly shorter circulatory arrest time (32 vs. 72 min, P<0.0001), but similar body ischemic times (76 vs. 72 min, N.S.). With the arch first technique, all but two patients awoke within 24 h, with an average delay of 9.3 h. In the distal first technique, two patients did not awaken and three patients showed delayed awakening, with an average awakening time of 24 h. The arch first technique led to one hospital death (2%), due to residual aneurysm rupture. Reversible ischemic neurological deficit (RIND) was complicated in three cases (6%), but no stroke occurred during operation. In the distal first technique there were four strokes, one RIND and three hospital deaths (12.5%). The arch first technique gave a significantly lower intra-operative stroke rate (P=0.0030) and smaller hospital mortality (P=0.0615). The arch first technique led to five late deaths, with an 84.5% 3 year survival rate, and the distal first technique led to six late deaths with a 59.1% 3-year survival rate. Conclusions: The arch first technique is clearly superior to the conventional distal first technique in surgical mortality and morbidity regarding neurological outcome, and provides a higher survival rate and better quality of life. The arch first technique is an excellent method for total arch replacement.
Keywords: Aortic arch; Survival analysis; Retrograde perfusion
; Quality of life;
Cerebral
protection
Article Outline
1. Introduction
Total arch replacement remains a challenging procedure in aortic surgery, although surgical results are improving following recent technical improvements [1], [2] and [3]. With improving morbidity and mortality, the quality of life after surgery becomes more important. We have performed total arch replacement by reconstructing the arch and arch vessels with a four-branched graft, under deep hypothermic circulatory arrest with retrograde cerebral
perfusion
, through median sternotomy [4]. Retrograde
cerebral
perfusion
provides a better operative field without complicated cardiopulmonary circuits, though there are time limitations on safe retrograde
cerebral
perfusion
. The safe interval is reported to be less than 60 min [5] and [6]. A shorter period of circulatory arrest should give better brain protection and faster neurological recovery after surgery. To reduce the hypothermic circulatory arrest with retrograde
cerebral
perfusion
time, we have adopted a modified arch first technique through median sternotomy since 1998 instead of the conventional distal anastomosis first technique [7], [8], [9] and [10]. We evaluate surgical results, including survival rate and quality of life, with the arch first technique, and compare these with values in patients who underwent the conventional distal first technique. This is not a randomized clinical study, but rather a retrospective comparative clinical study of operations performed by one surgeon. It provides clear information about the advantages of the present arch first technique.
2. Materials and methods
2.1. Patients
The modified arch first technique has been used in patients with arch or distal arch aneurysm involving the left subclavian artery not extending to the mid-descending aorta. Aortic arch aneurysm involving the mid-descending aorta has been replaced through a left thoracotomy, and is excluded from this study.
From 1998 to 2003 there were 50 consecutive cases who underwent the modified arch first technique by a single surgeon. Of these, 38 were male and 12 female, with an average age of 68 years ranging from 42 to 82 years. There were 33 true aneurysms, and 10 chronic and seven acute Stanford type A dissections. Twelve cases were operated on as emergencies. Concomitant procedures were aorto-coronary bypass grafting in four, Bentall operation [11] in two, and each of aortic valve replacement, aortic valve repair, Yacoub's procedure [12], and open distal stent grafting in a single patient. There were three cases of repeat surgery; the previous surgery was aortic valve replacement in two and ascending aortic replacement in one.
In the first 19 cases, the arch vessels were reconstructed with a hand made neoarch graft, and in the later 31 with a commercially available four branched graft (Hemashield, Boston Science Co.)
There were another 24 cases who underwent total arch replacement to reconstruct the arch vessels using the conventional distal first technique, operated on by the same surgeon from 1992 to 1998. The arch and arch vessels were replaced with a four branched graft by performing distal anastomosis, with the descending aorta first and then reconstructing the arch vessels under hypothermic circulatory arrest with retrograde cerebral
perfusion
.
These 24 cases comprised 14 males and 10 females, with an average age of 68 years. There were 16 true aneurysms and three chronic and five acute aortic dissections. Emergency operations for aortic dissection or aneurismal rupture were performed in 10 cases.
The groups were compared by means of the chi-square test and non-paired t-test, using the StatView J5.0 software package. A probability <0.05 was taken as significant.
2.2. Operative procedure for the arch first technique
Mitazolam (0.05 mg/kg) was given intramuscularly as a premedication. Anesthesia was induced by means of an intravenous injection of Mitazolam (0.1 mg/kg), Fentanyl citrate (10 mg/kg) and Vecuronium bromide (0.1 mg/kg), and was maintained with Fentanyl citrate (1–4 mg/kg/h) and Vecuronium bromide (2 mg/h) until the end of surgery, with or without Sevoflurane inhalation.
The patient was placed in the spine position and the aortic arch was exposed via a median sternotomy. Cardiopulmonary bypass was applied with bicaval drainage, and the ascending aorta was perfused after carefully inspection with direct echocardiography. Core cooling was initiated, with left ventricular venting. The aortic arch was touched as little as possible to minimize the release of debris prior to initiation of circulatory arrest. Barbital sodium (500 mg) and 20% mannitol (150 ml) was administered when the esophageal temperature had fallen to 22 °C. Perfusion
was discontinued once the esophageal temperature fell below 20 °C. An anesthetic-depth monitor (BIS monitor A-1050, Aspect Medical Systems Inc., MA), which is essentially a simplified EEG, is useful to monitor brain activity. Once this monitor shows a nearly flat level of EEG activity, circulatory arrest should be established. Cross clamping was applied to the ascending aorta just distal of the
perfusion
cannulae, and cold blood cardioplegia was given through the
perfusion
cannulae. The arch vessels were transected at their orifice, and each vessel was reconstructed with a four branched arch graft (Hemashield, Boston Science, Co.) with a 4-0 polypropylene running suture in the following sequence: left subclavian artery, left carotid artery, and brachiocephalic artery. Retrograde
cerebral
perfusion
(RCP) was applied via the superior vena cava (SVC) cannulae snared with an umbilical tape after reconstructing the left subclavian artery. The SVC pressure was maintained at approximately 10–15 mmHg, with 250–350 ml/min of flow rate without drainage from the inferior vena cava cannulae. The blood temperature was held at around 16–18°. After anastomosis of the arch vessels, the flow rate of RCP was increased to 700–800 ml/min to complete deairing and flush debris; the RCP was then stopped and antegrade
cerebral
perfusion
was resumed through the four branched arch graft, with clamping at both ends. The
perfusion
flow was maintained at 10–15 ml/kg/min so that the left radial artery pressure was above 30 mmHg (Fig. 1).
Fig. 1.
Operative procedure of arch first technique. The arch vessels were transected at their orifice and each vessel was reconstructed with a four branched arch graft under retrograde cerebral
perfusion
in the following sequence: left subclavian artery, left carotid artery, brachiocephalic artery. The antegrade
cerebral
perfusion
was resumed through the four branched arch graft, with clamping at both ends. Distal anastomosis was performed with another graft, using an elephant trunk technique.
The posterior wall of the arch aneurysm was incised to the descending aorta. The anterior wall of the arch was never dissected, in order to avoid injury to the recurrent laryngeal and phrenic nerves. Distal anastomosis was performed with a further graft, using an elephant trunk technique. A 5 cm long, reduplicated 10 cm graft was inserted into the descending aorta [13]. Four pieces of 2-0 polyvinylene suture were placed at each quarter position, then the distal anastomosis site was retracted with these so as to be shallower, and the running suture was completed with reinforcement on the adventitia using a teflon felt strip (Fig. 1). The distal graft was drawn back, and distal perfusion
to the lower body commenced with a Folly catheter inserted into the graft. Hemastasis was completed with additional sutures. The distal graft and arch graft were anastomosed with a 4-0 polypropylene running suture under
perfusion
of both grafts with a single blood pump (1.5 l/m2/min
perfusion
index or over 30 mmHg of the left radial artery pressure), and rewarming of the patient was begun. Cardiopulmonary bypass was then resumed through the arch graft and full
perfusion
flow (2.5–3.0 l/m2/min of
perfusion
index) was recovered after reaching 25 °C esophageal temperature; the patient was rewarmed fully. The ascending aorta was then transected at a
perfusion
cannula after giving cold blood cardioplegia. Proximal anastomosis between the arch graft and aortic root was completed with 4-0 polypropylene running sutures, and the total aortic arch reconstruction was completed.
3. Results
3.1. Surgical results of arch first technique
The mean operation time was approximately 7 h. The mean cardiopulmonary bypass time exceeded 3.5 h as a result of applying deep hypothermia, with an average lowest esophageal temperature of 18.6 °C. The mean circulatory arrest time with retrograde cerebral
perfusion
was 32 min, ranging from 20 to 59 min. However, the lower body ischemic time was 76 min because distal anastomosis was performed. The cardiac ischemic time was nearly 2 h, during which all of the aortic arch reconstruction procedures were performed.
All but 2 patients awoke within 24 h of completion of the operation, with an average delay of 9.3±9.9 h. Half of the patients were extubated within 24 h, though the average intubated period was nearly 2 days. Forty percent of patients remained in the ICU for just 1 day, but the average ICU stay exceeded 3 days. In 10 cases (20%) no blood transfusion was required. There was no surgical mortality, but one patient died as a result of residual descending aortic aneurysm rupture at 3 weeks after surgery. Reversible ischemic neurological deficit (RIND) was complicated during the operation in three cases (6%), but no stroke occurred. Another two cases suffered stroke on the 3rd and 10th postoperative days. Temporary psychiatric disorder, such as delirium, was observed in a further five cases (10%). Other morbidities were: re-sternotomy for bleeding in four, low output syndrome requiring high dose inotoropic support in two, and renal dysfunction showing over 3.0 mg/dl of blood creatine level in four.
All patients (except the one who died in hospital) were discharged without nursing care after an average hospital stay of 46 days following surgery.
There were five late deaths, as a result of stroke in 3 patients, pneumonia in one and residual aneurismal rupture in one. The 1 and 3 year survival rates were, respectively, 90.8 and 84.5% on an average follow-up period of 20 months (Fig. 2). Seventy three percentage of patients have no social disability, but there was slight social disability in nine and severe social disability in four patients (Table 1).
Arch first n=50 | Distal first n=24 | P-value | |
---|---|---|---|
Operation date | 1998–2003 | 1992–1998 | |
Male/female ratio | 38:12 | 14:10 | N.S. |
Age (range) | 67.9±8.1 (42–82) | 67.8±13.9 (37–88) | N.S. |
Disease (DAA/TAA) | 17:33 | 8:16 | N.S. |
Emergency | 24% | 42% | N.S. |
CABG | 8% | 8% | N.S. |
Valve surgery | 10% | 0% | N.S. |
Redo surgery | 6% | 0% | N.S. |
3.2. Comparison with distal first technique
Compared to the arch first technique, the distal first technique has a significantly longer operation time (525 min, P=0.0448) and a similar cardiopulmonary time (249 min, NS), but a shorter cardiac ischemic time (88 min, P=0.0003). The distal first technique has a significantly longer circulatory arrest time (72 min, P<0.0001), of similar duration to the lower body ischemic time in the arch first technique (76 min) with lower esophageal temperature (16.8 °C, P<0.0001).
Two patients did not awaken, and 3 patients suffered delayed awakening. There were no significant differences between the two techniques in the average awakening period (24 h) or average intubation period (40 h), but the distal first technique led to a significantly longer stay in ICU (7.7 days) and in hospital after surgery (77 days). All patients in the distal first technique required blood transfusion.
There were three hospital deaths (12.5%). The cause of death was bleeding in one, stroke in one and renal failure in one. Stroke was complicated in 5 patients, of whom four showed neurological sequela. Delirium occurred in four cases. Other morbidities were: re-sternotomy for bleeding in four, low output syndrome requiring high dose inotoropic support in three, and renal dysfunction with over 3.0 mg/dl of blood creatinine level in three. Relative to the distal first technique, the arch first technique gave a significantly lower intra-operative stroke rate (P=0.0030) and reduced hospital mortality (P=0.0615). There were six late deaths, of whom three died within one year of surgery. The 1, 2 and 3 year survival rates were, respectively, 72.7, 63.6 and 59.1%, which are lower than for the arch first technique although the difference is not statistically significant (P=0.0692, Fig. 2).
The quality of life in the 15 survivors was as follows: no social disability in eight, slight disability in two, severe disability in three, and two cases confirmed at their homes.
4. Discussion
Surgical results for total arch replacement have recently been improving, and several reports now show less than 5% surgical mortality [1] and [2]. This success shifts the goal from reducing surgical mortality and morbidity to improving the quality of life after surgery. We perform total arch replacement by reconstructing the arch vessels with a four branched graft under deep hypothermic circulatory arrest, with retrograde cerebral
perfusion
only through median sternotomy. We have always sought to improve surgical technique, especially
cerebral
protection which remains a major concern in aortic arch surgery. Hypothermic circulatory arrest with retrograde
cerebral
perfusion
is a simple technique. It can be performed without complicated
perfusion
circuits, and provides a better operative field for the graft anastomosis site with cervical vessels or the descending aorta [14]. However, retrograde
cerebral
perfusion
has the drawback of limited safe duration [15] and [16]. We have proposed that retrograde
cerebral
perfusion
should not exceed 60 min when sufficient flow is not present, because it is non-physiological
perfusion
[5] and [6]. We believe that a shorter period of retrograde
cerebral
perfusion
is better for
cerebral
protection and neurological recovery after surgery [17]. We, therefore, adopted the arch first technique so as to shorten the period of circulatory arrest with retrograde
cerebral
perfusion
. The present study shows that the arch first technique gives a shorter circulatory arrest time than the conventional distal first technique. This change should give better neurological outcome, shorten surgical recovery, and enhance quality of life even in the late phase after surgery.
Since this is not a randomized study, there could be bias in the present inferences. First, the distal-first technique was performed in the early period of the study. Even in a single surgical team there is a learning curve. Minor modifications were employed even in the arch-first technique, with the aim of improving the clinical outcome. Second, the proportion of emergency operations is higher in the distal first technique. This may influence the early clinical outcome, since mortality and morbidity are always several times greater for emergency operations (Table 2).
Arch first n=50 | Distal first n=24 | P-value | |
---|---|---|---|
Operation time (min) | 426±173 | 525±202 | 0.0448 |
Bypass time (min) | 212±49 | 249±171 | NS |
Cardiac ischemic time (min) | 119±32 | 88±33 | 0.0003 |
Circulation arrest time (min) | 32±9 (19–59) | 72±18 (35–113) | <0.0001 |
Lower body ischemic time (min) | 76±15 | 72±18 | NS |
Lowest esophageal temperature | 18.6±1.3 | 16.8±0.9 | <0.0001 |
Awakening period (h) | 9.6±9.9 | 24±34 | NS |
Intubation time (h) | 44±43 | 40±32 | NS |
ICU stay (day) | 3.4±3.2 | 7.7±6.3 | 0.0018 |
Hospital stay after surgery (day) | 46±18 | 77±82 | 0.0008 |
Non-blood trans fusion ratio | 20.0% | 0% | 0.0185 |
Delirium | 10% | 16% | NS |
Intra op. CV dysfunction | 6% | 21% | 0.0544 |
RIND | 6% | 4% | NS |
Stroke | 0% | 17% | 0.0030 |
Post op. stroke | 4% | 0% | NS |
Renal failure | 8% | 13% | NS |
Low output syndrome | 4% | 13% | NS |
Bleeding | 8% | 17% | NS |
Hospital mortality | 2% | 13% | 0.0615 |
No social disability | 73% | 54% | NS |
Slight social disability | 19% | 13% | |
Severe social disability | 8% | 20% | |
Confirmed in home | 0% | 13% |
The present study has demonstrated a significantly better intraoperative neurological outcome for the arch first technique. We believe that this is due to the shorter retrograde cerebral
perfusion
period. The arch first technique also led to an obvious reduction in hospital mortality and a clear improvement of the early survival rate and subsequent quality of life. We believe that surgical refinements should further improve clinical results.
Is selective cerebral
perfusion
better than retrograde
cerebral
perfusion
, since it is antegrade
perfusion
and maintains physiological circulation? Our patients show no difference in mortality or neurological outcome [5], but Okita [18] has reported a high incidence of delirium after retrograde
cerebral
perfusion
. However, selective
cerebral
perfusion
leads to the possibility of thrombo-embolism, since selective cannula may release debris from the clamping or snaring arch vessels, and may cause arterial injury. In the arch first technique, the aortic arch and arch vessels are scarcely touched, so that there is little chance of embolic complication. The arch first technique can, in fact, be classified as a selective
cerebral
perfusion
, since antegrade
cerebral
perfusion
is resumed through a branched arch graft which anastomoses each cervical vessel corresponding to a selective cannula. The arch first technique reduces the chances of releasing debris or arterial injury during selective
cerebral
perfusion
, and this is the main advantage of our technique. However, the arch first technique made no contribution to the delirium rate in this study; one cause of delirium is thought to result from
cerebral
ischemic damage during retrograde
cerebral
perfusion
.
The arch first technique does have some disadvantages. The relatively long lower body ischemic time may result in renal or hepatic dysfunction, poor recovery of gastrointestinal function or gastrointestinal bleeding. Recently, we have applied distal graft perfusion
with a Folly catheter. This allows lower body
perfusion
even during distal anastomosis of the descending aorta or graft-to-graft anastomosis. The technique should reduce the duration of lower body ischemia and may improve the recovery of renal, hepatic or gastrointestinal function.
Hemostasis of the distal anastomosis site of the descending aorta is the most important point for total arch reconstruction, because it sometimes causes fetal bleeding that demands massive blood transfusion. We have applied a modified elephant trunk technique with a replicated graft. Four pieces of 2-0 polyvinylene retracting sutures were applied so as to make the distal anastomosis site shallow, and a tight running suture was made to achieve perfect anastomosis. Graft perfusion
with a Folly catheter has the further advantage of confirming complete hemastasis of the distal anastomosis. With this technique, the proportion of patients requiring autologous blood transfusion decreases.
Median sternotomy also has certain advantages over left thoracotomy. In our experience, patients show quicker recovery of respiratory function after median sternotomy, and better quality of life with less wound pain in the late phase, than patients who underwent left thoracotomy. Also, the arch first technique is performed through median sternotomy with a small skin incision, since the arch vessels do not require full exposure.
We have performed individual anastomosis of each arch vessel with a four branched graft rather than island reconstruction. Elderly Japanese patients generally suffer from severe atherosclerotic changes on the orifices of each arch vessel. This technique is suitable for atherosclerotic aortic arches, because the arch vessels have fewer atherosclerotic changes. It also provides a better operative field for the distal anastomosis site or easy hemostasis for each anastomosis site. In the first 19 cases, we applied a handmade neoarch graft to reconstruct the arch vessels and give better exposure to the distal anastomosis site, but we now use a commercially available four branched graft. The length of each branched graft (several cm) allows mobilization of the arch graft and gives a better operative field, even for distal anastomosis sites. A four branched graft avoids a long suture line and simplifies the arch reconstruction.
In conclusion, we have presented our early clinical results of a recently refined arch first technique under circulatory arrest with retrograde cerebral
perfusion
. This technique is still developing, but some refinements definitely contribute to better clinical outcomes. The arch first technique is clearly superior to the conventional distal first technique in its surgical mortality and morbidity involving neurological outcomes. It also provides clinical results comparable to selective
cerebral
perfusion
, and has the advantage that thrombo-embolism is less likely. We believe that our improvement of the surgical technique involved may act as a useful reference and contribute to the improvement of aortic surgery.
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