Adult: Aorta
Application of deep hypothermic circulatory arrest in open left chest aortic aneurysm repair

https://doi.org/10.1016/j.jtcvs.2021.03.080Get rights and content

Abstract

Objectives

Deep hypothermic circulatory arrest (DHCA) is often required for patients undergoing repair of descending thoracic aortic aneurysm (DTAA) or thoracoabdominal aortic aneurysm via left thoracotomy when proximal crossclamping is not feasible or when aneurysmal disease extends into the transverse aortic arch. Historical literature suggests higher complications rates due to the technical complexity of this approach; we examined outcomes with this approach at our center.

Methods

Between January 2008 and May 2018, 84 patients with DTAA or Crawford extent I thoracoabdominal aortic aneurysm underwent open repair. DHCA was employed in 46 of 84 (55%) patients, of which 33 (72%) required repair of distal arch and DTAA, and 13 (28%) required repair of the distal arch and extent I thoracoabdominal aortic aneurysm. Patients who underwent DHCA had more chronic dissections than those in the non-DHCA group (70% vs 34%; P ≤ .05).

Results

Major adverse outcomes for the DHCA group versus non-DHCA group were as follows: early mortality 3 out of 46 (7%) versus 4 out of 38 (11%) (P = .70), stroke 3 out of 46 (7%) versus 1 out of 38 (3%) (P = .62), permanent spinal cord deficit 2 out of 46 (4%) versus 3 out of 38 (8%) (P = .65), permanent renal failure necessitating dialysis 1 out of 46 (2%) versus 2 out of 38 (5%) (P = .59). Freedom from major adverse outcomes was 38 out of 46 (83%) versus 31 out of 38 (82%) for DHCA versus non-DHCA (P = 1).

Conclusions

DHCA can be employed via left thoracotomy for combined arch and DTAA or extent I thoracoabdominal aortic aneurysm open repair.

Section snippets

Patient Cohort

The University of Florida Institutional Review Board approved this study (#2018-00734). A waiver of informed consent was granted because all collected data already existed in the medical records, and no contact with patients or study-related interventions occurred. We retrospectively reviewed patients treated with open repair of DTAA or Crawford extent I TAAA. Patients undergoing open descending thoracic aortic replacement or thoracoabdominal aortic replacement for other pathologies, such as

Patient Demographic Characteristics and Preoperative Variables

Eighty-four patients underwent open descending thoracic aortic or thoracoabdominal aortic replacement during the study period. Demographic data and patient characteristics are summarized in Table 1. DHCA was employed in 46 of these patients (55%). Of the patients who underwent DHCA, 33 patients (72%) underwent distal arch and DTAA repair, and 13 (28%) underwent distal arch and extent I TAAA repair. Partial CPB and permissive hypothermia (non-DHCA) was used in the remaining 38 patients (45%).

Discussion

Thoracic endovascular aortic repair (TEVAR) has become first-line therapy for aneurysms of the descending thoracic aorta, with reduction in morbidity and mortality compared with open surgical repair.10 We recently reported outcomes of 1037 patients who underwent TEVAR at our center, with early mortality of 3.6% and SCI rate of 3.3%.11 Open repair was only employed at our center when a patient's aneurysm was not amenable to TEVAR. This explains the frequent use (55%) of DHCA observed, due to

Conclusions

This contemporary series shows no evidence of increased morbidity and mortality when DHCA is employed via left thoracotomy for open repair of DTAA and Crawford extent I TAAA when proximal aortic clamping is not feasible.

Supported by the Herron Endowed Chair in Cardiothoracic Surgery at The University of Florida.

Accepted for the American Association for Thoracic Surgery Aortic Symposium 2020.

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© 2021 by The American Association for Thoracic Surgery