Open surgery for descending thoracic aorta in an endovascular era

Abstract

Background: Thoracic endovascular aortic repair has become the preferred treatment for a variety of descending thoracic aortic pathologies. However, there are unresolved issues such as morphologic appearance of chronic dissection, persistent false lumen perfusion, and adequacy of landing zone. Enthusiasm for improving the technique of open aortic repair and perioperative management is fading. In this study, we would like to demonstrate how we improve our surgical outcomes by establishing a dedicated aortic multidisciplinary team at the Kawasaki Aortic Center.Method: We performed a single-center retrospective study from January 2015 to December 2016. All patients with open descending thoracic aortic replacement were recruited. Preoperative patient demographic data, bypass strategies, operative details, and postoperative outcomes were reviewed.Result: From January 2015 to December 2016, we treated 168 cases of descending thoracic aortic repair using a left thoracotomy. Median age was 69.0 AE 21.8 years old, and 63.1% were aortic dissection (acute, 4.8%; chronic, 58.3%); 81.3% patients underwent elective operations. Left heart bypass, deep hypothermic circulatory arrest, and partial cardiopulmonary bypass were performed in 88.6%, 9.0%, and 2.4% of patients, respectively. Mean operative time was 312 AE 94 minutes. In-hospital mortality in total was 0.6%. The rate of transient spinal cord injury was 4.7%.Conclusions: Under a dedicated aortic multidisciplinary team, we demonstrated that open descending thoracic aorta replacement can be performed with excellent early outcomes with low reintervention rates, regardless of the nature of the aortic pathologies.

Miniaccess open repair of descending thoracic aorta

“…Even in the era of minimally invasive cardiac surgery, such approaches have not been widely utilized in open DTA repair because of the challenging nature of the procedures and their perceived high risks of perioperative morbidity and mortality. 1 , 3 Open DTA repair requires a comprehensive understanding of the anatomy and delicate control throughout the entire procedure, for which a fully exposed surgical field has been regarded essential for safe execution of the surgery. For this, extended thoracotomy involving large skin incision and cutting of the thoracic muscles/ribs has been regarded a requisite to achieve optimal surgical field.…”

“…Nevertheless, potential endoleak, risks of later reintervention, and less effectiveness in challenging aortic anatomy are major limitations of TEVAR, and these still leave questions regarding its long-term durability. 1 , 2 , 3 For these reasons, open DTA repair remains the most effective treatment option for DTA diseases, and its surgical outcomes have been improving with advances in surgical techniques and perioperative management. Open DTA repair requires extended thoracotomy involving a large skin incision with division of thoracic muscles and cutting costal cartilage/bone, which in turn carries extensive surgical trauma and its associated complications.…”

Open conversion with Crawford extent 3 thoracoabdominal aortic replacement after candy‐plug implantation

“…The operation was carried out with left thoracotomy via the sixth intercostal space as previously described. 3,4 After the thoracoabdominal aorta was exposed, the patient was put on cardiopulmonary bypass (CPB) via the left common femoral artery and vein. The mid of descending thoracic aorta and the infra-renal abdominal aorta were clamped and thoracoabdominal aorta was opened.…”

“…Careful studying of preoperative CT scan can help the former and meticulous identification of aortic wall layers especially the adventitia is important to help accomplish the latter. Based on the authors' experience, 3,4 we believe open surgery is the definitive solution to complex aortic pathology with durable long-term outcomes.…”

Commentary: Open surgery for descending thoracic aortic disease: “Pride and prejudice”

“…Paradoxically, surgeons will be increasingly challenged by the hurdles of secondary aortic procedures. 4 In this issue of the Journal, Fujikawa and colleagues 5 reported on their striking experience with OS. The article is kind of an old-school surgical report: straightforward, with an ample description of operative techniques, a minimalistic statistical approach, and a focus on a few clear, hard outcomes.…”