Nicholas T Kouchoukos1. 1. Division of Cardiovascular and Thoracic Surgery, Missouri Baptist Medical Center, BJC Healthcare System, St Louis, MO, USA. ntkouch@aol.com
Abstract
OBJECTIVE: Staged procedures for extensive aneurysmal disease of the thoracic aorta are associated with substantial cumulative mortality for the 2 procedures and death in the interval in between, often from aortic rupture. We have used a 1-stage procedure for operative repair of most, or all, of the thoracic aorta. METHODS: Ninety-five patients were treated using a bilateral anterior thoracotomy with transverse sternotomy, hypothermic circulatory arrest, and reperfusion of the arch vessels first to minimize brain ischemia. Fifty-six patients had chronic type A aortic dissections (all but 2 patients had a previous operation), 36 patients had degenerative aneurysms, and 3 patients had chronic type B aortic dissections with proximal extension. The ascending aorta and aortic arch were replaced in all patients combined with resection of varying lengths of descending aorta. RESULTS: In-hospital mortality was 8.4% (8 patients). Morbidity included reoperation for bleeding (11%), mechanical ventilation for more than 72 hours (48%), tracheostomy (17%), and renal dialysis (8%). Stroke occurred in 1 patient (1%). Seven of the 93 operative survivors (7.6%) have undergone successful reoperation on the graft (4 patients) or the contiguous aorta (3 patients). CONCLUSIONS: The 1-stage, arch-first technique is a safe and suitable alternative to 2-stage procedures for repair of thoracic aortic disease. Its effectiveness relative to more recently developed hybrid procedures awaits further analysis of long-term performance.
OBJECTIVE: Staged procedures for extensive aneurysmal disease of the thoracic aorta are associated with substantial cumulative mortality for the 2 procedures and death in the interval in between, often from aortic rupture. We have used a 1-stage procedure for operative repair of most, or all, of the thoracic aorta. METHODS: Ninety-five patients were treated using a bilateral anterior thoracotomy with transverse sternotomy, hypothermic circulatory arrest, and reperfusion of the arch vessels first to minimize brain ischemia. Fifty-six patients had chronic type A aortic dissections (all but 2 patients had a previous operation), 36 patients had degenerative aneurysms, and 3 patients had chronic type B aortic dissections with proximal extension. The ascending aorta and aortic arch were replaced in all patients combined with resection of varying lengths of descending aorta. RESULTS: In-hospital mortality was 8.4% (8 patients). Morbidity included reoperation for bleeding (11%), mechanical ventilation for more than 72 hours (48%), tracheostomy (17%), and renal dialysis (8%). Stroke occurred in 1 patient (1%). Seven of the 93 operative survivors (7.6%) have undergone successful reoperation on the graft (4 patients) or the contiguous aorta (3 patients). CONCLUSIONS: The 1-stage, arch-first technique is a safe and suitable alternative to 2-stage procedures for repair of thoracic aortic disease. Its effectiveness relative to more recently developed hybrid procedures awaits further analysis of long-term performance.