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J Thorac Cardiovasc Surg 2002;124:531-540
© 2002 The American Association for Thoracic Surgery
Surgery for Acquired Cardiovascular Disease (ACD) |
From the Division of Cardiovascular and Thoracic Surgery,a Department of Surgery, Saitama Medical School, Saitama, Japan, and the Division of Cardiovascular Surgery,b Osaka Prefectural Hospital, Osaka, Japan.
Supported by the Research Grant for Cardiovascular Disease (13A-2) from the Ministry of Health and Welfare.
Received for publication Aug 30, 2001. Revisions requested Dec 14, 2001; revisions received Jan 29, 2002. Accepted for publication Feb 7, 2002. Address for reprints: Masaask Kato, MD, Division of Cardiovascular & Thoracic Surgery, Saitama Medical School, 38 Morohonngou Moroyama-Chou, Irima-gunn, Saitama 350-0495, Japan (E-mail: mkato{at}xk9.so-net.ne.jp).
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Abstract |
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Introduction |
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1-4 However, because this surgical treatment has improved the life prognosis for the acute phase in recent years, 5-9 the discussion has been changing from the acute-phase mortality rate to postoperative morbidity and the prognosis of residual dissection in the chronic phase. 10-16 The shift has been prompted by relatively high late mortality 7,10-12 and experience with reoperation for enlargement of residual dissection in the aortic arch and descending aorta after the conventional operation to repair the ascending aorta. 11-16
Therefore for patients with type A aortic dissection who are forecast to have enlargement of residual dissection with only conventional ascending treatment, such as patients who are young (
60 years), have Marfan syndrome, or have residual entry in the arch or descending aorta, 11,12,14,16 we have introduced a method in which we implant the stent graft in the descending aorta from the surgically opened aortic arch simultaneously with graft replacement of the ascending aorta and the aortic arch. 17,18 The purpose is to avoid enlargement of the residual dissected aorta and difficult reoperations in the chronic phase. This new method is intended to obtain clotting formation and shrinkage of the false lumen by having the stent graft ensure entry-site closure in the aortic arch or descending aorta and continuous compression on the false lumen.
We evaluated the results of our procedure in terms of mortality and morbidity in the acute phase, late survival, and the outcome for the false lumen and dissected aorta in patients with type A aortic dissection.
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Methods |
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The 19 patients were selected for total arch graft implantation with open stent-graft placement because the entry site was located in the aortic arch or descending aorta and they had an enlarged aortic arch or descending aorta (>40 mm in aortic diameter), neck vessel dissection (in patients <60 years), or Marfan syndrome. The entry site was detected only in the ascending aorta in 3 patients, the ascending aorta and arch or descending aorta in 3 patients, and the arch or descending aorta in 13 patients. The locations of these entry sites were ascertained by means of aortography, transesophageal echocardiography, and direct intraoperative diagnosis. Dilatation of the aortic arch or descending aorta was seen in 3 patients. Neck vessel dissections were also observed in 12 patients and 23 arteries. In association with aortic dissection, 3 had a neurologic disorder, 3 had cardiac tamponade with shock, 1 had respiratory dysfunction, 3 had leg ischemia, and 2 had suspected intestinal ischemia. The clinical characteristics of the 19 patients are shown in Table 1.
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Imaging protocol
All 19 patients underwent chest radiography and spiral computed tomographic scanning, and 17 underwent aortography or digital subtraction angiography before the surgical procedure. The true luminal diameter (D) of the descending aorta was calculated from the planimetered circumference (Cf) of the true lumen measured by means of enhanced computed tomographic scanning as follows:
D = Cf/pi.
Description of the device
The surgical stent graft (Figure 1, A and B) was composed of a stainless-steel Z-shaped stent and polyester graft material. The triple tandem-type Gianturco stent (William Cook Europe A/S) was inserted in the distal part of a noncoated polyester fabric graft (Toray Medicals or Inter Vascular, Inc) with the crimp ironed out. These polyester grafts are usually used as the implanting graft in conventional thoracic and abdominal aortic aneurysm surgery. The stent was attached to the graft with a series of interrupted 5-0 polypropylene sutures. The device was described in detail in a previous study. 17
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Procedure
All procedures are performed with the patients under general anesthesia sustained by means of endotracheal intubation and mechanical ventilation. A Swan-Ganz catheter, left radial and unilateral temporal arterial line, and probe for transesophageal echocardiographic monitoring are inserted.
The patient is placed in a supine position, and median sternotomy is the surgical approach. Systemic heparinization (300 U/kg) is initiated before vessel cannulation. The arterial return cannula is placed in the right axillary artery. The femoral artery is also cannulated from the bifurcated arterial return line (Figure 2, A). Bicaval venous cannulas are usually inserted through the right atrium. Cardiopulmonary bypass is initiated, and flow rates are maintained between 2.4 and 2.8 L · min-1 · m-2.
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, B). After proximal anastomosis has been completed in the ascending aorta, bypass anastomoses from the 4-branch graft to the left subclavian artery and left carotid artery are performed, and the perfusion for these cervical branches is restarted from the 4-branch graft, through which the return cannula has been inserted (Figure 2, B). Perfusion to the lower body is discontinued when the brachiocephalic artery is perfused through the right axillary return cannula and left carotid artery, left subclavian artery, and coronary arteries through the 4-branch graft at around 1000 mL · min-1 · m-2 (Figure 2, B and C).
The aortic arch is transected at the predetermined proximal anastomotic line (between the brachiocephalic artery and the left carotid artery). During transesophageal echocardiographic monitoring, a 30F catheter sheath (Figure 1, C) that has been curved to correspond to the aortic arch for the individual patient and has been loaded with the stent graft is inserted through the proximal incision site to the intended distal attachment portion (ie, to the point at which tight contact between the stent graft and vascular wall is possible over a length of 25 mm; Figure 2, B). Once the sheath is placed across the entry in the descending aorta and the pushing rod is advanced within the sheath, the stent graft is deployed by holding the rod in position and withdrawing the sheath (Figure 2, B).
After the stent graft is deployed, a 14F Foley balloon is inserted into the graft and inflated to confirm that the stent graft is fully opened and not twisted or kinked. Blood is allowed to return from the femoral arterial cannulation to expel the air and atheromatous plaque that might have been dislodged by the stent-graft implantation. Subsequently, the proximal side of the stent graft is cut, its edges are trued up with those of the transected aortic arch, and an anastomotic stoma is created comprising the dissected aorta and the Teflon strip reinforcement externally by using interrupted mattress sutures (Figure 2, C). Finally, this anastomotic stoma is sutured together with the distal portion of the 4-branched graft in end-to-end anastomotic style.
After the air is eliminated from the femoral artery, the cardiopulmonary bypass is resumed, and surface and core rewarming are initiated. During the rewarming, the right brachiocephalic artery is reconstructed with one of the 4 branched grafts from the ascending aorta (Figure 2, D).
Patient follow-up
The patients were followed until March 2000 at the outpatient clinic or through telephone contact. The follow-up was 100% complete. The mean follow-up period was 2.4 ± 1.6 years, and the longest period was 5.5 years.
The effectiveness of stent-graft implantation in the acute phase was estimated by the closure of the targeted entry site and clot formation in the false lumen, as confirmed by means of transesophageal echocardiography on the day of the operation and enhanced computed tomography at 2 weeks after the operation.
The effectiveness of stent-graft treatment in the chronic phase was estimated from the change in diameter of the false lumen and dissected aorta. All cases, except one acute-phase death, were given prospective follow-up by means of enhanced computed tomography at approximately 2 weeks (10-25 days after treatment), 6 months (4-6 months after treatment), 1 year (10-14 months after treatment), and annually thereafter.
The diameters of the dissected aorta and false lumen were measured at 3 predetermined levels in each computed tomographic examination, including the preoperative computed tomographic scan (Figure 3). The first measurement level was at the maximum diameter of the descending aorta in the short axis, the second was at the distal end of the stent graft, and the third was 50 mm distal to the second measurement.
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Statistical analysis
All continuous data are expressed as means ± SD. Survival was estimated by using the Kaplan-Meier method. Changes in the diameters of the false lumen and dissected aorta between the preoperative period and 6 months after the operation were analyzed with the paired t test. All calculations were performed with a Statcel for Excel 98 on a Mac OS.
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Results |
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Postoperative computed tomographic scanning 1 to 4 weeks after the operation depicted complete thrombosis of the aneurysm or the false lumen surrounding the stent graft in all but 2 patients. In these 2 patients we had ligated the left subclavian artery from inside the opened aortic arch and observed retrograde leakage from the ligated left subclavian artery to the false lumen. Even in these patients, complete thrombosis of the false lumen was observed on the computed tomographic scan after coil embolization to the root of the left subclavian artery by using transbrachial catheter intervention. In the patients with a preoperative narrowed true lumen in the descending aorta, aortography and computed tomographic scanning after stent-graft implantation documented remarkable recovery of the true lumen to a round shape and thrombosis of the false lumen. Bypass grafts for the cephalic vessels were patent in all patients.
Early mortality and morbidity
The early results of total arch graft implantation with a stent graft are shown in Table 2. One of the 19 patients died (9 days postoperatively), for an in-hospital mortality of 5.3%. This operative death occurred in the patient with annuloaortic ectasia who received aortic root reconstruction simultaneously with total arch graft implantation (patient 5). The patient died as a result of postoperative stroke, low-output syndrome, mediastinitis, and consequent multiorgan failure.
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No pulmonary complication resulted, and there was one case of postoperative hoarseness. The postoperative intubation period was 5 days or less in 15 patients and more than 5 days in 4 patients, and no patients needed tracheostomy. Two (10.5%) patients required temporary hemodialysis. In one patient (patient 7) hemodialysis was performed for reperfusion injuries in the leg and intestine that were related to a preoperative ischemic condition. This patient also required a laparotomy for investigation, but no resection of the intestine was necessary. The second patient for whom hemodialysis was administered (patient 19) had a postoperative ischemic event in the visceral artery and both legs. This postoperative ischemia was successfully treated by means of bare stent implantation into the narrowed true lumen of the thoracoabdominal aorta on the second postoperative day. There were 3 cases of mediastinitis, all of which were treated with mediastinal washing, irrigation, and drainage. In 2 of the patients, we were able to perform omental flap implantation after thorough washing and drainage, and the third patient was the only case of death in this series (patient 5). The early results of total arch graft implantation with the stent graft are shown in Table 2.
Late mortality and morbidity
The survivals for all patients 1 and 3 years postoperatively were 89.5% and 82.6%, respectively. There were 2 late deaths: One patient committed suicide 3 months after the operation, and the other patient died of cardiac and pulmonary complications.
Two nonfatal events related to the operation were noted in the chronic phase. In one patient a reoperation was required for seroma in the mediastinum caused by the bypass graft (polytetrafluoroethylene graft) to the cervical branch. The other patient required an additional stent-graft implantation from the femoral artery (transluminal-placed endovascular graft) 1 year after the initial operation to close an intrathoracic residual entry site that was not detected before the initial operation. This patient (patient 10) is the only one who needed reoperation related to dissection of the aorta. The late mortality and morbidity of all patients are shown in Table 2.
Outcome for the dissected aorta and false lumen
With the aid of 46 examinations, we observed serial size changes in the false lumen and the dissected aorta in 17 patients at the first 6 months after the stent-graft placement and thereafter. Computed tomographic examinations were performed according to schedule in 15 patients, but follow-up computed tomographic examinations were discontinued in 2 patients at 6 months and 2 years because aging kept them from unassisted walking and they could not come to our outpatient clinic for follow-up. At the level of the end of the stent graft, the data on 2 patients were omitted from serial follow-up data because in both patients there was no aortic dissection and false lumen at that level through the entire period. At the level 5 cm distal to the stent graft, the data on 5 patients were omitted for the same reason.
Postoperative computed tomographic examinations at 6 months showed that all 17 false lumens at the level of maximum aortic diameter had clotted, that the diameter of the false lumen at that level had been reduced by more than 50% in 16 (94.1%) patients, and that the aortic diameter had been reduced by more than 20% in 11 (64.7%) patients. Two more patients had a greater than 20% reduction of the aortic diameter after 6 months. The mean diameter of the false lumen at 6 months was 4.1 ± 6.4 mm (vs 22.1 ± 7.9 mm preoperatively), the mean aortic diameter was 32.4 ± 8.9 mm (vs 42.1 ± 6.7 mm preoperatively), and both were significantly decreased compared with preoperative diameters. At the same level, the mean diameters of the false lumen and the dissected aorta were 2.1 ± 3.4 and 30.5 ± 6.2 mm, respectively, at 1 year and 3.0 ± 4.8 and 31.0 ± 7.2 mm, respectively, at 2 years. The changes in the diameter of the false lumen and the aorta are shown in Figure 3. In the follow-up period no patient had an enlargement of the aortic diameter greater than 20% from the preoperative state at this level.
At the level of the end of the stent graft, the false lumen was absent in 2 patients and already clotted at the initial (preoperative) computed tomographic examination in 5 others. Of the 10 patent false lumina at this level, 8 (80%) were completely clotted at 6 months. There was a residual patent false lumen at this level in one patient (patient 7) as a result of back flow from an abdominal re-entry site near the celiac artery. The other instance of a patent false lumen resulted from flow from an intrathoracic residual entry site that could not be detected at the initial operation (patient 10). In one case of a preoperatively clotted false lumen, a postoperatively reopened false lumen with a postoperative new entry site was noted as the result of a postoperative ischemic event in the lower body (patient 19).
At this level, the false lumen had been reduced by more than 50% from the preoperative diameter in 9 (60%) of 15 patients at 6 months, and the aortic diameter had been reduced by more than 20% in 6 (40%) of 15 patients. After 6 months, the aortic diameter showed this amount of reduction in 2 other patients. The mean diameter of the false lumen at 6 months was 6.6 ± 8.0 mm (vs 15.5 ± 8.1 mm preoperatively), and the mean aortic diameter was 31.4 ± 8.5 mm (vs 34.3 ± 4.7 mm preoperatively); both were significantly decreased compared with preoperative diameters. At the same level, mean diameters of the false lumen and the dissected aorta at 1 year were 3.2 ± 5.9 mm and 28.4 ± 8.0 mm, respectively, and the respective mean diameters were 4.3 ± 4.8 mm and 28.0 ± 7.2 mm, respectively, at 2 years. In the follow-up period, 2 (13.3%) patients had greater than 20% enlargement of the aortic diameter compared with its preoperative state at this level; in both patients (patients 7 and 19) the computed tomographic scans showed a patent false lumen 6 months after the operation. There were no cases in which the aortic diameter was larger than 60 mm (ie, should have been be considered for reoperation).
The following measurements all pertain to the level 5 cm distal to the stent graft. Among 9 patent false lumina (a false lumen was absent in 5 patients and already clotted at the initial computed tomographic examination in 3 patients), 3 (33.3%) patients had total clotting 6 months after the operation. A greater than 50% reduction of the false lumen diameter compared with the preoperative diameter was observed in 6 (50%) of the 12 patients, and greater than 20% reduction of the aortic diameter was observed in 2 (16.7%) of the 12 patients 6 months after the operation. The mean diameter of the false lumen 6 months after the operation was 11.4 ± 9.3 mm (vs 17.1 ± 7.3 mm preoperatively), a significant decrease compared with preoperative diameter, and the mean aortic diameter was 30.1 ± 5.9 mm (vs 30.8 ± 3.4 mm preoperatively). The mean diameters of the false lumen and the dissected aorta at 1 year were 7.8 ± 10.1 and 27.3 ± 6.1 mm, respectively, and those at 2 years were 16.0 ± 14.5 and 33.0 ± 8.7 mm, respectively. In the follow-up period, 3 (25%) patients had greater than 20% enlargement of the aortic diameter relative to the preoperative state. Two of them were the same patients (patients 7 and 19) with enlargement at the level of the end of stent graft; the other (patient 8) had the case of suspected Marfan syndrome, in which there was a large re-entry site near the celiac artery. There were no cases in which the aortic diameter was larger than 60 mm (ie, should have been considered for reoperation).
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Discussion |
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The surgical mortality for graft replacement of the ascending aorta for type A dissection has been reported as ranging from 9% to 21.8%, 5,11,19 and that of total arch graft replacement has been reported as ranging from 17% to 55%. 19-27 Surgical mortality in our series was 5.3%. The rate of cerebral, respiratory, and renal complications has been reported as 2.5% to 11.8%, 6% to 19%, and 5% to 12.2%, respectively, in the conventional surgical treatment. 3,5-7,19 In our series the rates of cerebral and renal complications (5.3% and 10.6%, respectively) were comparable with those of conventional treatment. The rate for respiratory complication in our series (0%, no patient needed a tracheostomy) was much lower than that seen in previous reports because our technique does not require us to touch the recurrent nerve and phrenic nerve or to open the thorax and compress the left lung. Also, even in 3 patients (patients 7, 8, and 16) with preoperative critical ischemia of the leg or organs, the patients recovered after the initial operation. (Postoperatively, however, a new entry site was observed in a different patient [patient 19], followed by ischemia in the visceral organs and both legs.) These good results in the acute phase seemed to be associated with the stent-graft procedure's reduced invasiveness, complete entry-site closure, and secure perfusion to the lower body.
The ordinary motivation for total arch graft replacement for type A dissection is to prevent enlargement of the residual dissection. There are few reports of meticulous follow-up of residual dissection after the ascending operation for type A dissection. The reported rate for enlargement of residual dissection was 17% at 3 years from the initial operation 13 and 37% at 5 years. 15 Enlargement after the initial operation was enhanced in patients who had a patent residual false lumen, were young, or had Marfan syndrome. 11,12,14-16 The rate of patent residual false lumen after the ascending operation for type A dissection was 47% to 83%. 7,14,15,28,29 Two causes have been proposed to account for these high rates: a residual entry site in the arch descending aorta or neck vessels and leakage from the distal anastomosis in ascending graft replacement. On the other hand, the dissected aorta in type B dissection is destined to enlarge if its maximum diameter is greater than 40 mm in the acute phase. 30 To reduce the rate of enlargement of residual dissection after the operation for type A dissection, we should completely separate the entry site from the false lumen, especially in the patient who is young, has Marfan syndrome, or has a maximum aortic diameter of greater than 40 mm in residual dissected aorta and not create a new entry site in the distal anastomotic portion. To meet these requirements, we performed total arch graft implantation with a stent graft on targeted patients who were highly likely to have aortic enlargement of residual dissection if treated only with graft replacement of the ascending aorta (ie, those who were young, had Marfan syndrome, or had a maximum dissected aorta of >40 mm and an entry site in the arch-descending aorta or had neck vessel dissection). In our surgical treatment with the stent graft, we obtained clotting of the residual dissection in 80%; enlargement of the residual dissection was observed in only 2 (13.3%) patients at the level of the end of the stent graft, with a mean follow-up period of 2.4 years. Additional aortic treatment related to residual dissection was required in only one (5.9%) patient. The number of data on residual dissection was limited (10 patients for the level of the end of the stent graft, 9 for 5 cm distal to the stent graft), and the follow-up period was short. Nevertheless, these data concerning dilatation and additional treatment in the chronic phase were satisfactory enough, considering that the targeted patients in our series were highly likely to have enlargement of residual dissection if they had received the conventional surgical treatment. Furthermore, this total arch graft-implanting method has an advantage, even in the patient who postoperatively has residual dissection in the descending aorta, because the additional transcatheter stent-graft placement can be easily implanted through the femoral artery after achievement of local anesthesia. 18,31-33
In our experience with this series, some unpleasant complications were observed in exchange for satisfactory fate of the residual false lumen. There were 2 cases of paraparesis (which is a seldom-seen complication after conventional treatment); however, they were temporary. In these patients the end of the implanted stent graft was placed at the level of T6, and circulatory arrest of the lower body was accomplished within 40 minutes with hypothermia. The hypothesized reasons for this complication are air or thromboembolism caused by insertion of the stent graft or complete clotting and stoppage of blood flow to the Adamkiewicz artery that branched from the false lumen. 34 Meticulous air and thrombus elimination during the stent-graft insertion, along with perioperative spinal protection, might be needed to protect against this terrible complication. Also, the relatively high incidence of mediastinitis (3/19 patients) might be related to the long operative time associated with this operation. Refinements in procedure and greater facility with this new operation should reduce or eliminate these troublesome complications.
With our approach, there might be some risk of intimal trauma because of the continuous compression of the stent graft on the dissected and weakened intimal wall, but in the small number of recent reports of stent-graft placement for acute aortic dissection, there was no report about this anxiety. 18,32,33 In postmortem examinations of our cases of surgical death, the following were observed: clotting of the false lumen, slight hyalinosis of intimal wall, and no thinning of the intimal wall. In fact, stent-graft implantation for acute aortic dissection was associated with quick clot formation and shrinkage of the false lumen after stent-graft implantation, and this healing process might promote good blood supply to the intimal wall from the adventitia and subsequently play a role in preventing new trauma to the intimal wall. In any case the proper size adjustment of the stent graft and the device selected might be key to preventing trauma to intima that is dissected and might be fragile.
In summary, our preliminary experience with the total arch graft implantation with a stent graft for the selected patient with type A aortic dissection suggests that this new procedure might provide better surgical results in the acute and chronic phase, especially with regard to the fate of the false lumen, than does conventional treatment.
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Acknowledgments |
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, Data of each case in which false lumen at the level is patent; , data of each case in which false lumen at the level is completely thrombosed; 
, mean ± SD.