J Thorac Cardiovasc Surg 2004;127:1827-1829
© 2004 The American Association for Thoracic Surgery
Retrograde segmental aortic repair for type II thoracoabdominal aortic aneurysm
Teruhisa Kazui, MDa,*,
Katsushi Yamashita, MDa,
Hitoshi Terada, MDa,
Naoki Washiyama, MDa
a First Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
Received for publication December 21, 2003; revisions received January 13, 2004; accepted for publication February 4, 2004.
* Address for reprints: Teruhisa Kazui, MD, First Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, 431-3192 Japan
tkazui{at}hama-med.ac.jp
Surgical treatment of type II thoracoabdominal aortic aneurysms (TAAAs) is associated with high morbidity and mortality1 because the procedure is complicated and adjuncts for spinal cord and visceral protection are required. To this end, a distal aortic perfusion through a left heart bypass has recently been used in type II TAAA repair.2,3 We have been using partial femorofemoral bypass as a distal aortic perfusion in the treatment of descending thoracic aortic aneurysms and TAAAs.4,5 However, we have became aware that a retrograde perfusion from the femoral artery carries the risk of producing a malperfusion of visceral organs in a chronic aortic dissection. We therefore have modified our technique for this lesion.
Patients and methods
Patient data
Five patients with a chronic aortic dissection underwent TAAA repair with the modified technique. They ranged in age from 26 to 65 years with a mean of 49 years. Four patients had a typical Marfan syndrome and had previously undergone cardiovascular operations for a DeBakey type I dissection with aortic root, a total arch, and either proximal descending thoracic replacement or the elephant trunk technique. The remaining patient did not have Marfan syndrome and showed a DeBakey type IIIb dissection. A preoperative aortogram and computed tomographic scanning showed a diffuse aneurysmal formation of the thoracoabdominal aorta and perfusion of some visceral arteries from the false lumen, suggesting a potential risk of organ malperfusion if a retrograde perfusion were to be used (Figure 1).
View larger version (66K):
[in this window]
[in a new window]
|
Figure 1. Preoperative aortogram (left) and diagram (right) of patient with Marfan syndrome who had previously undergone aortic root replacement with composite valved conduit, total arch, and proximal descending aortic replacement showing complicated circulatory status of visceral arteries.
|
|
Surgical technique
After the patient was fully heparinized, a long venous drainage cannula was inserted into the right atrium through the femoral vein. The infrarenal abdominal aorta and both distal iliac arteries were crossclamped. Next, each distal limb of a Y-shaped, woven Dacron polyester fabric graft was sutured to a corresponding iliac artery (Figure 2, B). The proximal aortic clamp was shifted proximally just below the diaphragm, after which the celiac axis, superior mesenteric, and both renal arteries were cannulated and perfused with a roller pump at a flow rate of 100 mL/min for each artery (Figure 2, C). The visceral arteries were reconstructed either by having the celiac axis, superior mesenteric, and right renal arteries attached to the graft, with the left renal artery connected separately, or a by technique in which the visceral arteries were separately implanted with graft interposition. After the visceral arteries were reimplanted, the crossclamp on the graft was moved proximally, restoring perfusion to the visceral organs from a side arm attached to the previously implanted Y-shaped graft (Figure 2, D). Subsequently, the aortic clamp was moved to the descending thoracic aorta, two pairs of the intercostal arteries (T11, T12) were exposed, and back bleeding from these arteries was put under control with Fogarty balloon catheters. The arteries were reconstructed with side-armed grafts that had already been attached to the main graft. After the reconstruction, the clamp on the graft was shifted more proximally to perfuse the reimplanted intercostal arteries. Afterward, two or three pairs of proximal intercostal arteries (T8, T9, T10) were reimplanted in a similar fashion (Figure 2, E). The average number of critical intercostal arteries in the T8 to L1 range was four for this series. Finally, a proximal graft anastomosis was performed and the operation was completed (Figure 2, F).
View larger version (39K):
[in this window]
[in a new window]
|
Figure 2. Modified type II thoracoabdominal aortic replacement technique in chronic aortic dissection. See text for detail.
|
|
Results
All the patients survived their operations and were discharged from the hospital. With respect to postoperative morbidities, 1 patient who had undergone TAAA repair along with a reimplantation of T9, T10, T11 and T12 had paraparesis develop, which may have been caused by prolonged hypotension resulting from hemorrhage. Pulmonary failure requiring prolonged respirator support was noted in this case. However, neither renal failure, liver dysfunction, nor intestinal ischemia was present. A postoperative aortogram showed satisfactory reconstruction of the thoracoabdominal aorta and visceral and intercostal arteries (Figure 3).
View larger version (65K):
[in this window]
[in a new window]
|
Figure 3. Postoperative aortogram and diagram of same patient as in Figure 1 after type II TAAA repair by retrograde segmental aortic repair technique, showing satisfactory reconstruction of thoracoabdominal aorta, celiac axis, superior mesenteric and both renal arteries, and T9, T10, T11, and T12 intercostal arteries.
|
|
Discussion
We have previously seen a patient with a chronic aortic dissection in whom bowel ischemia with multiple organ failure developed after a conventional antegrade segmental extent type II TAAA repair with the aid of a femorofemoral bypass and a selective visceral perfusion. We speculated that this complication may have been related to a malperfusion of the visceral organ as a result of the retrograde femoral perfusion. Whenever there is any reason to believe that retrograde perfusion from the femoral artery will cause a malperfusion of the abdominal organs, then a segmental aortic repair, starting from the distal aortic side, appears to be a valid alternative in type II TAAA. Profound hypothermic circulatory arrest with antegrade perfusion is an alternative to this method if proximal aortic clamping is not technically feasible.
References
- Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ. Experience with 1509 patients undergoing thoracoabdominal aortic operations. J Vasc Surg. 1993;17:357–370[Medline]
- Coselli JS, LeMaire SA. Left heart bypass reduces paraplegia rates after thoracoabdominal aortic aneurysm repair. Ann Thorac Surg. 1999;67:1931–1934[Abstract/Free Full Text]
- Safi HJ, Miller CC, Yawn DH, Iliopoulos DC, Subramaniam M, Harlin S, et al. Impact of distal aortic and visceral perfusion on liver function during thoracoabdominal and descending thoracic aortic repair. J Vasc Surg. 1998;27:145–153[Medline]
- Kazui T, Komatsu S, Yokoyama H. Surgical treatment of aneurysms of the thoracic aorta with the aid of partial cardiopulmonary bypass: an analysis of 95 patients. Ann Thorac Surg. 1987;43:622–627[Abstract]
- Kazui T, Komatsu S, Sasaki T, Yamada O. Graft inclusion technique for thoracoabdominal aortic aneurysms involving visceral branches with the aid of a femoro-femoral bypass. J Cardiovasc Surg. 1987;28:663–670[Medline]
