Extended replacement of aortic arch aneurysms through left posterolateral thoracotomy

Abstract

Objective: To present our experience of total aortic arch replacement through a left posterolateral thoracotomy. Methods: Sixteen patients (13 males; mean age 62.1 AE 11.3 years) with extended thoracic aortic aneurysms, including those in the thoracoabdominal aorta, underwent replacement through a left posterolateral thoracotomy. The pathology of the diseased aorta was non-dissecting aneurysm due to aortitis in 1 patient and aortic dissection in 15 patients (acute type A: 1, chronic type A: 12, chronic type B: 2). In a prior operation, the patient with aortitis had undergone the Bentall procedure with endovascular stenting of the brachiocephalic artery, and among the other 15 patients, one previously had endovascular stenting for the aortic arch and 12 had hemi-arch replacement for acute type A dissection. Extension of arch replacement was the aortic arch and descending aorta in eight patients, the ascending arch and descending aorta in five patients and the descending arch, and thoracoabdominal aorta in three patients. Additional retroperitoneal dissection was required for the repair of a thoracoabdominal aortic aneurysm. Results: One patient died of traumatic cerebral hemorrhage on day 145 (hospital mortality 6.3%). Average duration of ventilation support was 19.4 AE 17.0 h and length of ICU stay was 3.6 AE 1.6 days. Actuarial survival at 2 years after the operations was 67.7%. However, no aortic-related mortality was observed during follow-up. Conclusions: Early results of extended aortic arch replacement through a left posterolateral thoracotomy were satisfactory in selected patients. #

Open stent grafting for complex diseases of the thoracic aorta: clinical utility

“…The average mortality in the analyzed series was 4.7 %. These results are similar to those of open aortic arch repair, and these results are considered acceptable when compared with the 9.5 % mortality rate reported after first-stage repair with the conventional elephant trunk procedure [14–19], 10.0 % mortality rate after 1-stage extensive aortic replacement with left thoracotomy [20–25], or 9.8 % mortality rate after TEVAR to the landing zone 0 with total arch rerouting [26–31] (Table 2). …”

Elephant trunk procedure 27 years after Borst: what remains and what is new?

“…As Table 2 shows, lower mortality rates, especially in patients undergoing redo surgery for chronic aortic dissection involving the distal aortic arch and the proximal descending aorta, have thus been reported [28][29][30][31][32][33][34]. However, the long operating times associated with extensive one stage or total replacements of the entire aorta [33,34]; the higher pulmonary complication rates, ranging from 15% to 50%; the need to sacrifice both internal mammary arteries; the postoperative pain; and the inability to extend resection to segments downstream from the diaphragm, have limited their applicability and acceptance considerably.…”

“…The presence of a significant interval mortality between the two stages ranging from 3% to 13%, the fact that only 45% of patients, who underwent first-stage ET, returned for second-stage completion, and the complications related to the second stage have convinced some surgeons to perform, whenever possible, a one-stage repair, through a clamshell [28][29][30], transmediastinal [31] or left posterolateral thoracotomy approach [32]. As Table 2 shows, lower mortality rates, especially in patients undergoing redo surgery for chronic aortic dissection involving the distal aortic arch and the proximal descending aorta, have thus been reported [28][29][30][31][32][33][34].…”

Selective Cerebral Perfusion with the Open Proximal Technique during Descending Thoracic or Thoracoabdominal Aortic Repair: An Option of Choice to Reduce Neurologic Complications

“…The advantage of SCP is that it permits a longer duration of CA, allowing more complex aortic repairs to be performed. Okada et al 9) and Hino et al 10) reported that SCP provided excellent brain protection during aortic repair through a left thoracotomy; however, both of their patient cohorts underwent the one-stage repair of extended thoracic aneurysms and the approach to the aortic arch differed from our technique. Hagl et al 11) noted that adjunctive SCP increased the permissible duration of CA from 40 min to 80 min for aortic arch surgery via a median sternotomy.…”