One-Stage Intrathoracic Repair of Extended Aortic Aneurysms

Abstract

Aneurysms of the entire thoracic aorta are usually approached in two to three stages. From 1990 to 1994, we performed one-stage aortic replacement from the root to the diaphragm in 16 patients (8 men and 8 women with a mean age of 55.7 years, range 49 to 73). There were 11 type A dissections, 7 of which were acute. Six patients underwent aortic valve reconstruction; seven had aortic root replacement by Bentall or Cabrol techniques. In two cases, the innominate artery had to be replaced by a vascular graft separately in addition to reimplantation of the supraaortic branches as an island flap into the arch prosthesis. In eight cases, a median sternotomy was used; eight had a bilateral transverse thoracotomy. The procedure was performed under deep hypothermic circulatory arrest in all cases (mean duration 50.5 min, range 38 to 62 min). Two patients, both operated upon for an acute dissection, expired perioperatively: one due to a bronchopneumonia, and one because of a thrombosed Cabrol graft to the right coronary artery. No patient developed bleeding or neurological complications. At a mean follow-up of 26.9 months (1 to 50 months), all patients discharged from the hospital were still alive. Four patients underwent subsequent thoracoabdominal aortic replacement. This experience suggests that complete thoracic aortic replacement can be performed in a single session with an operative risk comparable to that of the conventional two-stage approach. The bilateral transverse thoracotomy affords excellent exposure. The lack of spinal cord ischemia may be the result of spinal cord protection with hypothermic circulatory arrest and use of the open-clamp technique.

Progress of the treatment for extended aortic aneurysms; is the frozen elephant trunk technique the next standard in the treatment of complex aortic disease including the arch?☆

“…It may be because of complexity and/or too much invasiveness of this approach. The summarized mortality of this one-stage repair is 8.9% as shown in Table 3 [7,8,32,[34][35][36]. However, some variants are listed in this table, each of them with a limited number of patients.…”

“…To accomplish extensive aortic replacement with a onestage approach, some operative methods have been devised as following: (1) through a median sternotomy [31], (2) with a median sternotomy + lateral thoracotomy or thoracoabdominal incision [8,32], (3) through a lateral thoracotomy [7], and (4) with a bilateral anterior thoracotomy (clamshell incision) [34][35][36]. Despite acceptable early results from those reports, this one-stage approach appears not to be widespread.…”

The frozen elephant trunk technique for the treatment of extensive thoracic aortic aneurysms: operative results and follow-up☆

“…Treatment of aortic arch aneuryms extending beyond the origin of the left subclavian artery either requires a twostage approach employing the elephant trunk operation as described by Borst or an extensive single-stage procedure performed through a clamshell incision [1,[3][4][5][6][7].…”

“…The conventional elephant trunk operation necessitates a reoperation through lateral thoracotomy, because the perigraft space around the elephant trunk remains perfused thereby promoting further aneurysmatic dilatation of that aortic segment [2,6,7]. As opposed to this, the 'frozen' elephant trunk technique as described here allows for progressive thrombus formation in the perigraft space in the descending aorta up to the level of the stents.…”

“…Nevertheless, staged repair carries the cumulative risks of two major surgical procedures, one through median sternotomy and the other through lateral thoracotomy [2]. This perception drove further developments in this field aimed at achieving complete repair of such extensive lesions by one single procedure [3][4][5][6][7]. The introduction of a new type of hybridprosthesis combining the features of a conventional vascular prosthesis and a stentgraft enables single-stage repair through median sternotomy [8].…”