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2 13 4 Table 1 Patients profiles and surgical procedures ( ) Surgical procedures Age Gender Dissecting: Preoperative complications (Cases: period) (Years) (Male: Female) True aneurysm Cerebrovascular Dis.: 1 Left thoracotomy : : 16 Chronic renal failure: 2 (n=31: ) (39-81) Active pneumonia: 1 Left thoracotomy with rotation : 4 5 : 8 Ruptured: 1 (n=13: ) (62-78) Cerebrovascular Dis.: : : 19 Chronic renal failure: 2 (14-84) (n=43: ) CPAOA: 1, Ruptured: 5 Patients profiles and surgical procedures: Left thoracotomy, distal hemiarch replacement via left thoracotomy; Left thoracotomy with rotation, left thoracotomy with rotation of the body to the left side; Median sternotomy, total arch replacement via median sternotomy; Chronic renal failure; chronic renal failure with hemodialysis; CPAOA, cardiopulmonary arrest on arrival arch first technique 5,6 Table debris χ 2 unpaired t-testp < 0.05 SD Table Table Table
3 Table 2 Surgical procedures ECC time RCP time Hospital death (Cases: period) (min.; mean SD) (min.; mean SD) (Cause of the death) Left thoracotomy % (n=31: ) (17-42) (Cerebral infarction: 2; LOS: 1) Left thoracotomy with rotation % (n=13: ) (25-34) (Cerebral infarction: 2) % (22-45) (LOS: 2, Bowel infarction: 1) (n=43: ) ECC, Extracorporeal circulation; RCP, Retrograde cerebral perfusion; LOS, low output syndrome Table 3 Cases of perioperative cerebral infarction (Cases of hospital death) Surgical procedures Dissecting aneurysm True aneurysm Total (Cases: period) Left thoracotomy 1 / 15 : 6.7% 4 / 16: 25.0% 5 / 31: 16.1% (n=31: ) No aftereffect (2 / 16: 12.5%) (2 / 31: 6.5%) Left thoracotomy with rotation 2 / 8: 25.0% 2 / 13: 15.4% 0 / 5: 0% (n=13: ) (1 / 8: 12.5%) (1 / 13: 7.7%) 2 / 24: 8.3% 3 / 43: 7.0% 1 / 19: 5.3% No aftereffect (0 / 43 : 0%) (n=43: ) Cases of cerebral infarction at operation, dissecting versus true aneurysm. = = 7 debris debris
4 13 4 Fig. 1 Retrospective findings of the CT scans of the patients suffering from the perioperative cerebral infarction (A) or not (B). White arrows indicate the transected lines. Severe atheromatous change of the aortic wall is detected at the transected line in A. A B CT Fig. 1 Ergin 10 debris 6.7 5,6 4.5 debris elephant trunk 11 trap door ,6 debris 12,13 1 Kanda, K., Satoh, S., Okano, T., et al.: Ascending aortic cannulation via left thoracotomy for distal aortic arch aneurysm operation. J. Cardiovasc. Surg., 43: , Crawford, E. S., Coselli, J. S. and Safi, H. J.: Partial cardiopulmonary bypass, hypothermic circulatory arrest, and posterolateral exposure for thoracic aortic aneurysm operation. J. Thorac. Cardiovasc. Surg., 94: , Kieffer, E., Koskas, F., Walden, R., et al.: Hypothermic circulatory arrest for thoracic aneurysmectomy through leftsided thoractomy. J. Vasc. Surg., 19: , Doi, K., Satoh, S., Hirai, J., et al.: A new double lumen balloon catheter for retrograde cerebral perfusion via jugu- 10
5 lar vein cannulation. ASAIO J., 43: M , Rokkas, C. K. and Kouchoukos, N. T.: Single-stage extensive replacement of the thoracic aorta: the arch-first technique. J. Thorac. Cardiovasc. Surg., 117: , Kanda, K., Satoh S., Okano, T., et al.: Arch-first reconstruction via median sternotomy. Short retrograde cerebral perfusion. J. Cardiovasc. Surg., 42: , Takamoto, S., Matsuda, T., Harada, M., et al.: Simple hypothermic retrograde cerebral perfusion during aortic arch replacement. A preliminary report on two successful cases. J. Thorac. Cardiovasc. Surg., 104: , Katoh, T., Gohra, H., Hamano, K., et al.: Right axillary cannulation in the left thoracotomy for thoracic aortic aneurysm. Ann. Thorac. Surg., 70: , Westaby, S. and Katsumata, T.: Proximal aortic perfusion for complex arch and descending aortic disease. J. Thorac. Cardiovasc. Surg., 115: , Ergin, M. A. and Griepp, R. B.: Progress in treatment of aneurysms of the aortic arch. Wolrd J. Surg., 4: , Borst, H. G., Frank, G. and Schaps, D.: Treatment of extensive aortic aneurysms by a new multiple-stage approach. J. Thorac. Cardiovasc. Surg., 95: 11-13, Wind, G. G. and Valentine, R. J.: Thoracic aorta. Anatomic exposures in vascular surgery. 1st. ed. Baltimore, 1991, Williams & Wilkins, Borst, H. G., Bühner, B. and Jurmann, M.: Tactics and techniques of aortic arch replacement. J. Card. Surg, 9: , Left Thoracotomy for Distal Aortic Arch Aneurysm Operation Attempt to Prevent Cerebral Disorders Tsutomu Matsushita, Shinichi Satoh, Keiichi Kanda, Takahisa Okano, Katsuhiko Oka, Taiji Watanabe, Yasuyuki Shimada, Hitoshi Yaku and Nobuo Kitamura Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine Key words: Aortic arch aneurysm, Surgical approach, Left thoracotomy, Median sternotomy, Cerebral infarction Left thoracotomy is selected as the standard approach for distal aortic arch aneurysm operation in our institute. To prevent cerebral disorders, we introduced the following three methods; 1) ascending-aortic cannulation to avoid retrograde arterial return from the lower body during cardiopulmonary bypass, 2) retorograde cerebral perfusion using a specially designed balloon catheter in the internal jugular vein, 3) to prevent the atheromatous thrombus from falling into the aortic root during proximal anastomosis, the body was rotated to the left side to bring the ascending aorta to a higher position than the descending aorta. The results of the distal arch replacement via left thoracotomy in comparison with the total arch replacement via median thoracotomy were discussed. Cerebral infarctions (embolisms) during operative procedures were compared among three groups including distal aortic arch replacement via left thoracotomy, distal aortic arch replacement via left thoracotomy with left-side body rotation, toal aortic arch replacement via median sternotomy. The percentages of cerebral infarction in the above 3 groups were 13.2%, 15.4% and 7.0%, respectively. The mortalities due to cerebral infarctions were 6.5%, 7.7% and 0 %, respectively. Cerebral infarctions were also compared in the different pathological types of aneurysms (i. e. due to dissection or atherosclerosis). There were no significant differences between the three groups of dissecting aneurysm. On the other hand, among true aneurysms, both the morbidity and mortality rates were higher in groups and than those in group. Despite several new technical achievements, the mortality and morbidity rates of cerebral infarctions in distal aortic arch replacement via left thoracotomy were still higher than those in total aortic arch replacement via median sternotomy. We conclude that median sternotomy rather than left thoracotomy should be selected as a standard approach for distal aortic aneurysm operation. Left thoracotomy still can be chosen for the limited cases of dissecting aneurysm when distal extension is needed. Jpn. J. Vasc. Surg., 13: ,
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