Open repair of descending thoracic aneurysms

Abstract

Introduction: Current strategies for operative treatment of a thoracic aortic aneurysm consist of open repair with surgical graft replacement or endovascular exclusion. To reduce mortality and morbidity of open repair, a multimodal approach has gradually evolved by maximizing organ protection.

Methods: On a total of 1108 patients treated in our Center from 1993 for pathology involving the thoracic aorta, we reviewed the prospectively collected data of 194 consecutive patients who underwent open thoracic aortic aneurysm repair, 104 (54%) for degenerative aneurysms, 65 (34%) for dissections, 25 (12%) for other pattern of disease. Left Heart Bypass was used in 82% of cases, clamp and sew technique in 16%, hypotermic circulatory arrest in 2%.

Results: Overall perioperative mortality was 4.1%. The rate of pulmonary complications was 8.8%. The rate of cardiac complications, i.e. new onset myocardial necrosis demonstrated by positive blood tests, was 6.2%. The rate of renal complications was 7.2%. Cerebrovascular accident, defined as a new neurologic deficit lasting more than 24 hours confirmed by imaging, occurred in 2.0% of patients. The rate of spinal cord ischemia, manifesting either as paraplegia or paraparesis, was 4.6%.

Conclusions: Mortality and morbidity rates of open thoracic aortic aneurysm repair are currently satisfactory especially in fit patients. In order to define surgical indications and the role of endovascular repair, consideration of age of the patient, comorbidity, symptoms, life expectancy, likely quality of life (if asymptomatic), aortic diameter, aneurysm morphology, aneurysm extent, suitability of landing zones, and operator experience are all distinctly relevant.

Keywords: Marfan syndrome; aortic surgical graft; open aortic repair; thoracic aortic aneurysm; thoracic aortic dissection; type B aortic dissection.

Figure 1

This image depicts a three-dimensional rendering of the entire aorta in a patients with a descending thoracic aortic aneurysm obtained with the OsiriX and the Fovia high definition volume rendering software.

Figure 2

Customized angulated (non orthogonal) cutting planes are extremely useful when studying a particularly angulated descending thoracic aneurysm. (Osirix screen capture - right).

Figure 3

A very tortuous structure may not be represented by a straight cut. A curved cut, opportunely hand-drawn on the axial scan (green line) can depict the course of this iliac access in a single reformatting plane. (Osirix screen-capture - right).

Figure 4

A curved plane (green line) allowed depicting the path of the Adamkiewicz artery (*) in this patient, clearly showing its continuity with the false lumen of its dissected aorta (arrow). (OsiriX screen capture).

Table 1

Results of open descending aortic repair. Updated personal series (*).

Figure 5

This image obtained with the OsiriX software and the Fovia high definition volume rendering software allows a pseudo-realistic three-dimensional depiction of the human body highlighting different structures. This kind of images can be useful to plan the surgical access to the thoracic aorta and the ideal intercostal space for thoracotomy.

Figure 6

The picture shows a left thoracotomy in the fifth intercostal space. The left lung has not been excluded yet (A). In rare cases the we perform a double left thoracotomy (B) in order to have a better access to the distal and proximal aorta.

Figure 7

Itraoperative pictures showing two alternative inflow sites for left heart bypass. A: cannulation of the left superior pulmonary vein is shown. B: cannulation of the proximal descending thoracic aorta. A single purse string suture reinforced with pledgets is generally used to close the breach on vein and a double one on the aorta.

Figure 8

A) depicts complete isolation of a large aneurysm involving the entire descending aorta right before cross-clamping of the proximal neck between left common carotid and subclavian arteries. B) shows final aortic reconstruction with bypass grafting with a conventional Dacron graft.

Figure 9

Surgical treatment of a chronic dissection using deep hypothermic circulatory arrest (note the absence of aortic cross-clamping). The true (TL) and the false lumen (FL) are clearly recognizable. The origin of the left subclavian artery (LSA) and the vagus nerve (VN) are also visible.

Figure 10

Surgical picture (A) and postoperative CT (B) showing critical intercostal artery reimplantation (arrow) to the aortic graft by means of single Dacron bypass.