treatment of thoracic and thoracoabdominal aortic aneurysms: technical
notes and the use of left heart bypass
Chiesa1, Germano Melissano1,
Marcelo Ruettimann Liberato de Moura1, Efrem Civilini1,
Yamume Tshomba1, Matheus Ruettimann Liberato de Moura1,
Silvio Magrin2, Andrea Carozzo2
Department of Vascular Surgery, Università Vita-Salute, IRCCS
San Raffaele, Milan, Italy.
2. Department of Anesthesiology, Università
Vita-Salute, IRCCS San Raffaele, Milan, Italy.
Dr. Roberto Chiesa
Department of Vascular Surgery
IRCCS H. San Raffaele
Via Olgettina, 60
20132 - Milano - Italia
The aim of this study was to analyze perioperative morbidity and
mortality in patients undergoing thoracic and thoracoabdominal aortic
aneurysm surgery at the Department of Vascular Surgery of IRCCS
San Raffaele, Milan.
The study included 332 patients (256 males and 76 females) with
a mean age of 65 (range from 34 to 82 years) undergoing 333 operations
for aneurysmectomy of thoracic and thoracoabdominal aortic aneurysm
between January 1988 and October 2002. Cerebrospinal fluid drainage
was used in 212 cases (75% of thoracoabdominal aortic aneurysms,
53% of thoracic aortic aneurysms); 215 patients (110 thoracoabdominal
aortic aneurysms and 105 thoracic aortic aneurysms) were operated
under left heart bypass using a Biomedicus pump.
The overall mortality rate at 30 days was 40/332 (12%); a total
of 32 deaths (10.5%) were recorded during elective surgery and eight
(29.6%) in patients undergoing emergency repairs. The following
perioperative complications were reported: paraplegia/paraparesis
in 21 cases (6.3%), respiratory failure requiring prolonged intubation
in 79 cases (24%), cardiac complications (major arrhythmia, myocardial
infarction) in 29 cases (9%), renal failure in 23 cases (7%), postoperative
bleeding requiring redo surgery in 17 cases (5%), graft infection
in six cases (1.8%).
Morbidity and mortality consequent to thoracoabdominal aortic aneurysm
and thoracic aortic aneurysms surgery are still high. However, based
on our experience, the use of an active distal circulatory support,
sequential cross-clamping and cerebrospinal fluid drainage enables
acceptable results to be achieved and reduces complications secondary
to spinal cord and visceral ischemia, without the need for expeditious
words: aortic aneurysm, thoracic aneurysm, abdominal aneurysm,
cardiac surgical procedures, heart-assist devices.
Palavras-chave: aneurisma aórtico, aneurisma torácico,
aneurisma da aorta abdominal, procedimentos cirúrgicos cardíacos,
Vasc Br 2002;1(3):207-18
problems are related to the surgical treatment of thoracic and thoracoabdominal
aneurysms and their anatomical localization. These problems are secondary
to massive blood losses, extensive surgical exposure, radical hemodynamic
alterations and mainly to the limited tolerance of organs subject to
a temporary ischemia during aortic clamping.
clamping of the descending aorta, the arterial pressure proximal to
the clamp increases rapidly, and this is accompanied by a sudden fall
in the pressure distal to the clamped aorta. The high elevation of the
cardiac postload results in increased ventricular tension and hence
also in preload. This results in an increased right heart pressure and
central venous pressure. Such cascade of events leads to a rise in venous
pressure and cerebrospinal fluid pressure. As a direct consequence of
interrupted aortic flow, the organ below the clamping point is deprived
from the normal oxygen intake and energy substrates, and has a reduced
removal of cellular catabolites.
of the hypoperfusion affecting the spinal cord, kidneys, intestine and
liver are of particular clinical interest (Table 1).s
1 - Complications of thoracoabdominal
aorta surgery reported in the literature
acute myocardial infarction
are currently several strategies to reduce the duration and extent of
devices: including extracorporeal circulation, shunt, sequential cross-clamping,
retrograde perfusion and cerebrospinal fluid drainage (CSFD);
strategies: including the selective reattachment of intercostal arteries
critical for spinal cord perfusion, selected through somatosensory evoked
potentials (SEP) or motor evoked potentials (MEP);
of metabolic activity: using moderate or profound hypothermia;
aids: such as the use of mannitol, steroids, scavengers and new agents
to prevent spinal cord damage caused by ischemia or reperfusion.
A total of
333 operations for descending thoracic aortic or thoracoabdominal aneurysms
were carried out from January 1988 and October 2002 at the Vascular Surgery
Department of IRCCS S. Raffaele in Milan on 332 patients (256 males and
76 females) with a mean age of 65 years (range 34-82). These included
a patient suffering from chronic aortic dissection (Stanford type B) who
initially underwent isthmus repair and, three years later, complete replacement
of the descending thoracic aorta due to the subsequent dilatation of the
Table 2 shows the anatomical distribution of the treated aneurysms.
2 - Distribution of cases
in this series according to aneurysm size
n. of cases
according to Crawford
§ Percentage referred to TAAA
repair was performed on thoracic or thoracoabdominal aneurysms with
restricted indications until 1993 (symptomatic aneurysms, emergency
surgery following rupture, voluminous aneurysms) and subsequently on
all patients, extending the indications for surgery to the guidelines
set out in the recent literature (Table 3).2
3 - Surgical indication
of risk factors
Close instrumental follow-up
Magnetic resonance, annual CT
diameter < 5 cm
diameter between 5-8 cm
the scant information available concerning the expansion rate and
risk of rupture of aneurysms, the data reported in the literature
delegate indications for surgery to the individual Centers depending
on their results and surgical series. A clinical and instrumental
evaluation of the risk-benefit ratio for each individual case must
be made in relation to surgical risk factors and possibilities of
Diameter > 8 cm
Expansion rate > 1 cm/year
age and clinical status
respiratory and renal function
diameter and expansion rate
to the Società Italiana di Chirurgia Vascolare ed Endovascolare
the preoperative, intraoperative, and follow-up periods have been collected
for all patients referred to our department with this pathology since
was of atherosclerotic origin in 278 patients (84%). Type B aortic dissection
was observed in 46 cases (14%); two cases were treated for para-anastomotic
pseudoaneurysm in a previous suprarenal abdominal aortic replacement,
one case of mycotic aneurysm in a patient undergoing dialysis and five
pseudoaneurysms of the isthmus and descending aorta in patients injured
in previous car accidents.
73 patients (22%) were symptomatic (Table 4). Surgery was elective in
92% of cases (305 patients) and urgent in 8% (27 patients).
4 - Symptoms on presentation
(excluding emergency cases)
undergoing elective surgery were submitted to multiplanar scans of the
thoracic and abdominal aorta using magnetic resonance (MR) with weighted
T1 and T2 SE sequences (Toshiba MRT 50, 0.5 Tesla) and, until December
1994, we used also subtraction digital angiography. From January 1995
onwards, the aorta was only studied using angio-MR + Gd DTPA bolus (GE
Med. Syst. Horizon IST) (Figure1).
1- Type 2 thoracoabdominal aortic aneurysm using angio-MR.
selected for surgery were also submitted to cardiological screening using
ECG and to examination by a specialist, which was extended, if necessary,
using thallium-dipyridamole scintigraphy or echo-stress test in cases
of suspected coronary pathology. Those patients with positive results
underwent also coronarography, and possible myocardial revascularization
prior to aortic repair.
preoperative use of TSA color Doppler ultrasonography enabled those patients
with surgically relevant carotid stenosis to be identified. They were
then submitted to carotid endarterectomy prior to major vascular repair,
thus reducing the risk of neurological ischemic events correlated with
the radical hemodynamic alterations during aortic surgery.
screening was completed by assessment of peripheral arterial system using
color Doppler ultrasonography of the lower limbs. Lung function was studied
using chest X-ray, blood gas analysis and respiratory function tests (FVC,
FEV1 and FEV 25-75%).
of patients for surgery starts in the ward approximately one hour before
admission to the operating room, with the administration of antibiotic
prophylaxis (IV cefazolin 2 g.) and premedication (IM scopolamine 0.25-0.5
mg.; oral diazepam 0.1 mg/Kg, IM morphine 0.1 mg/kg). Ten units of concentrated
erythrocytes, 10 units of frozen fresh plasma and 10 units of platelet
concentrate were available.
was induced using peripheral venous access with a 14G needle cannula in
the right arm. In the operating room, an 18G peridural catheter was then
positioned at level T6-T7 for perioperative analgesia.
was then induced and the double lumen endotracheal tube (Robertshaw) for
monopulmonary ventilation was inserted and monitored using fibroscopy.
If compression of the tracheal bifurcation by a voluminous aortic dilatation
is present, there is a consequent risk of left main bronchial or aneurysm
rupture. In these situations it would be preferable to use a single-lumen
tube with a bronchial excluder (Univent).
pressure was monitored by cannulation of the radial and right femoral
arteries to control proximal and distal pressure during aortic clamping.
The venous accesses were then completed using 4-lumen central catheter
in the right subclavian vein and a high capacity 3-lumen catheter in the
right internal jugular vein.
The use of
a vesical catheter with a thermometric sensor allows body temperature
to be monitored in the phase of moderate hypothermia during aortic clamping.
the subarachnoid catheter for CSFD (14G Tuohy needle) in the intervertebral
space between L2 and L3 or L3 and L4, the patient was positioned in the
right lateral decubitus (shoulders 60°, pelvis 30°) propped up
by a beanbag.
The patient was then sterilized to create an operating field extending
from the left axillary cavity to mid thigh and from the spine to the right
anterior axillary line.
thoraco-phreno-laparotomy in the 6th intercostal space, with proximal
section or resection of the 6th rib when necessary, the aneurysmatic aorta
was then isolated (Figure 2). The isolation phase may be facilitated by
excluding the left lung. Monopulmonary ventilation is maintained throughout
thoracic aorta replacement. In favorable anatomic situations the tendinous
center of the diaphragm may be preserved with a limited phrenotomy, which
reduces the time required for respiratory weaning3 (Figure 3).
2 - Preparation of aneurysm involving the entire thoracoabdominal aorta
3 - Limited phrenotomy can reduce respiratory weaning times.
care must be taken when isolating the proximal neck in the thoracic aorta,
which can be supported using a vessel-loop. The insertion of a large esophageal
probe makes it easier to identify and detach the esophagus from the proximal
aortic neck. The vagus and the source of the recurrent nerve must also
be identified at this stage since they can be damaged during isolation
and clamping maneuvers. Identification and clipping of some "high"
intercostal arteries can sometimes facilitate the preparation for the
proximal anastomosis, thus reducing aortic bleeding.
aorta as far as the bifurcation and the splanchnic vessels at source are
identified and isolated using transperitoneal access, with medial visceral
rotation after left parietocolic groove resection. This access allows
preoperative exploration of the viscera and enables the correct revascularization
following aortic reconstruction to be evaluated.
low-dose heparinization (70 UI/Kg) was used in all patients to prevent
embolization and preserve the microcirculation during clamping.
left circulatory assistance, the left atrium was cannulated (32 Fr angled
cannula) after making a pericardial incision posterior to the course of
the phrenic nerve. In the event of difficult cannulation owing to previous
heart surgery or the presence of atrial thrombosis, the pulmonary veins
or descending aorta can be cannulated. More recently the descending aorta
is the site of choice to proximal cannulation.
method for distal perfusion, given its relative simplicity, is the direct
cannulation of the subdiaphragmatic aorta (20-24 Fr flexible cannula).
A careful evaluation of preoperative CT or angio-MR makes it easier to
recognize the ideal site for aortic cannulation, avoiding areas with intraluminal
thrombus, which might cause peripheral embolization. This method avoids
an inguinal incision and the need to reconstruct the femoral artery (Figure
4 - Atriodistal cannulation for left bypass with centrifugal pump.
is then completed external to the operating field with the interposition
of a centrifugal pump and reservoir. In addition to the basal circulation,
a heat exchanger can be also associated, together with a supplementary
arterial line onto which four 9 Fr occlusion/perfusion catheters (Pruitt-Inhara)
are fixed to allow the selective perfusion of visceral arteries (octopus).
The body temperature is maintained around 32 °C (moderate hypothermia).
on the circuit allow constant monitoring of bypass flow, enabling better
control of distal aortic and visceral perfusion. It is initially kept
low (500 ml/min) to avoid retrograde embolization and then increased after
aortic clamping. Distal aortic pressure should be about 70 mmHg, a value
that is achieved using a mean flow between 1,500 and 2,500 ml/min. These
flow rates should correspond to 2/3 of the basal cardiac output measured
at the start of surgery.
cross-clamping is used from the aneurysm proximal tract, and when necessary,
has been done between the carotid and left subclavian arteries ensuring
control of aneurysms extending proximally as far as the isthmus. The aorta
is resected transversely and the proximal anastomosis is prepared using
graft (Dacron woven double velour soaked in collagen) and 3-0 polypropylene
thread for all aortic sutures, with reinforcement pledgets (teflon) at
points of maximum tension. The complete section of proximal aortic neck
allows the anastomosis to be made avoiding esophageal lesions when passing
the suture thread (Figure 5).
5 - Proximal clamping and complete resection of the aneurysm neck.
is then moved caudally and the aorta is resected at the diaphragm; any
"critical" intercostal arteries (T8-L2) are anastomosed at
the prostheses by attaching the aortic segment including the source
of the vessel (Carrel's patch). The last clamp is positioned on the
infrarenal aorta or iliac arteries depending on the aneurysm distal
extension. After resecting the abdominal aorta, visceral hematic perfusion
is maintained by the pump using occlusion/perfusion catheters (9 Fr)
inserted selectively into the splanchnic vessels. Currently we perform
perfusion of renal arteries with a cold crystalloid solution and the
celiac trunk and superior mesenteric artery receive normothermic blood
of visceral vessels generally enables them to be attached to the prosthesis
using Carrel's patch. In some cases, the source of the visceral arteries,
in particular the left renal artery, was set apart from the aneurysm and
required individual anastomosis, either directly or using a graft. During
this phase the presence of any lesions creating stenosis at the source
of the visceral arteries can be corrected using endarterectomy or bypass.
More recently, we have performed direct open stenting during operation
in patients with ostial stenosis of visceral arteries (Figure 6).
6 - Open stenting of the celiac trunk before introducing the cold perfusion
in a type 4 aneurysm.
we proceeded to prepare the anastomosis with the distal aorta (Figure
7).When the aortic dilatation ended at the level of the renal arteries
a distal beveled anastomosis was prepared, including the visceral and
distal aorta together.
7 - Final result of a type 2 aneurysm repair, with an aortic left renal
3 and 4 aneurysms we used mainly a less invasive approach with limited
phrenotomy, systemic low-dose heparinization (70 IU/Kg), simple aortic
clamping and selective cold perfusion of the visceral arteries (superior
mesentery and celiac trunk: Ringer lactate +4°C; renal arteries: Ringer
4°C + mannitol 18% 70 ml, 6-methylprednisolone 500 mg in 500 ml).
of the procedure, after the removal of the perfusion cannulae and heparin
antagonization using sulfate protamine, careful hemostasis was performed
with closure of residual aortic wall covering the graft. The use of biological
glue and absorbable knitted fabric of oxidized cellulose or fibrillar
collagen may have an important role in obtaining blood-tight anastomosis.
Before re-expanding the left lung, two suction thoracic drainage tubes
(32 Fr) and one retroperitoneal periprosthetic drainage (Jackson-Pratt)
fluid drainage (CSFD) and distal aortic perfusion (DAP) were not used
in emergency surgery. CSFD was maintained throughout the intraoperative
period and for the first three postoperative days, thus keeping cerebrospinal
fluid pressure below 10 mm/Hg; this period was extended if neurological
follow-up included chest X-ray, abdominal color Duplex scan (in cases
of TAAA) at one month after surgery, angio-MR after three months and a
check-up at 6 months and thereafter annually using CT or angio-MR.
circulation was used in 215 cases in the form of left heart bypass (110
TAAA and 105 TAA), associated with sequential cross-clamping in TAAA.
Almost all type IV and some type III TAAA were perfused with cold Ringer
solution (34 cases). Deep hypothermia was used in seven cases with circulatory
aortic clamping time was 48 minutes (range 25-107 min).
identification of "critical" intercostal arteries resulted
in their reattachment to the body of the prosthesis using Carrel's patch
in 62 cases.
In 13 cases the left renal artery was attached separately to the prosthesis
(using 6-mm Dacron prostheses in nine cases). Endarterectomy of the
visceral artery ostium was performed in 14 cases, four cases underwent
preoperative PTA-stenting of the renal arteries; no patients required
additional revascularization surgery (bypass). Four patients were treated
with intraoperative stenting: two renal arteries, one celiac trunk and
one superior mesenteric artery.
fluid drainage (CSFD) was used in 212 cases (75% of TAAA, 53% TAA).
The mean quantity of fluid drained intraoperatively was 70 ml (range
12-180 ml) and 380 ml (range 5-635 ml) postoperatively. There were a
total of 6 intraoperative deaths (four cases of uncontrollable hemorrhage,
two cases of cardiac arrest).
mortality at 30 days was 40/332 cases (12%), with 32/305 deaths (10.5%)
in patients undergoing elective surgery and 8/27 (29.6%) in emergency
operations (Table 5).
5 - 30-day mortality rates
in our series
to TAA, § referred to TAAA.
n. of cases
of death were: multiple organ failure in 12 cases, bleeding in 11 cases,
cardiac complications in nine cases; systemic embolization in four cases,
cerebral ictus, intraoperative aortic thrombosis, synchronous aneurysm
rupture and visceral aortic patch rupture in one case, respectively.
major complications were reported: respiratory failure requiring prolonged
intubation in 79 patients (24%); renal failure in 23 (7%), temporary
hemodialysis in 14 cases, bleeding requiring redo surgery in 17 (5%);
paraplegia/paraparesis in 21 patients (6.3%) (Table 6), associated in
one case with complete thrombosis of basilar artery aneurysm that was
not diagnosed prior to surgery, cardiac complications (major arrhythmia,
myocardial infarction) in 29 patients (9%) and 6 cases of prosthetic
infection (1.8%) related to chylothorax in one patient.
6 - Neurological morbidity
rate in our series
to TAA, § referred to TAAA.
n. of cases
of surgical repair of thoracic and thoracoabdominal aneurysms have gradually
improved over the past few years, the indications for treatment based
essentially on the size of the aneurysm are increasingly inadequate.
Several authors have recently looked for a more personalized risk/benefit
ratio of surgery based on objective data. 5,6
From these studies we conclude that, in addition to the real dimensions
(based on 3D reconstructions), the risk of rupture is aggravated by
old age, the co-presence of chronic obstructive bronchopulmonary disease
and symptoms related to the aneurysm. This risk of rupture must however
be compared with cofactors that aggravate the risk of surgery, in particular
old age, the presence of symptoms correlated with aneurysm and preoperative
renal insufficiency (Figure 8). 7
8 - A,B) Stratification risk curves for onset of postoperative complications
following TAAA repair.
of surgery on thoracic and thoracoabdominal aorta secondary to aneurysmatic
pathology have markedly improved since 1965, when S.E. Crawford introduced
the inclusion technique which, by significantly reducing surgical time,
allowed repair to be done by simple clamping.8-10
pioneering results, a number of additional methods of organ protection
were introduced, and as a result no other field of vascular surgery
possesses such a wide variety of surgical techniques. This diversity
is mainly based on the persistent risk of perioperative organ damage
(in particular, the spinal cord and kidneys) and on the multifactorial
nature of these severe events. Extremely divergent data continue to
be reported in the literature concerning the incidence of paraparesis/paraplegia
and postoperative renal failure (Table 1).
two diverse schools advocating antithetical methods of organ protection.
The lack of a precise etiopathogenetic definition gives equal authority
to both of them, which have developed over the past two decades, with
comparable results (Table 7, Table 8).11-19
Some authors state the need to maintain adequate visceral and spinal
cord perfusion during aortic clamping (passive shunts, extracorporeal
circulation methods, fluid drainage, reattachment of critical intercostal
arteries, intrathecal administration of vasodilators).11,15,17,19,21
In contrast, others prefer to use simple aortic clamping (clamp and
sew) convicted that more rapid surgery results in a lower percentage
7 - Results of TAAA surgery
using simple clamping method reported in the literature
to TAA, § referred to TAAA.
8 - Results of TAAA surgery
using distal aortic perfusion method reported in the literature
to TAA, § referred to TAAA.
aortic perfusion (DAP)
all the series reported agree on the close correlation between aortic
clamping time and the risk of spinal cord injury, as was clearly demonstrated
by Crawford in a series of 1,509 patients (Figure 9).
9 - Risk of paraplegia correlated with aortic clamping time.
prolonged aortic clamping (> 100 min) and the presence of preoperative
renal dysfunction are predictive factors for the onset of acute postoperative
renal failure. All authors agree that this severe complication drastically
reduces (p < 0.001) the short-term and long-term22 survival of operated
of assisted circulation was initially proposed by Cooley et al.23
in 1957 using left heart bypass.
of left heart bypass allows a mean distal perfusion pressure to be obtained,
which is higher than 60 mm/Hg during sequential aortic cross-clamping.
The employment of selective additional perfusion of visceral arteries,
using occlusion/perfusion catheters linked to the pump (Octopus), enables
the entire replacement of thoracoabdominal aorta to be made with continuous
visceral perfusion. By using these additional methods, the duration
of "hot" visceral ischemia (in particular, renal ischemia)
is reduced to few minutes (range 2-7 min in our series) required to
explore and cannulate the arterial openings with perfusion catheters.
By augmenting the duration of clamping tolerance, visceral perfusion
contributes to a higher level of surgical accuracy and precision.
in left ventricular tension is also achieved with this method, which
decreases preload and prevents hypertension of the proximal aorta. This
hemodynamic control cannot be achieved with the same efficacy by extraluminal
unless vasodilators are used (sodium nitroprusside and/or anesthetic
drugs).26 Moreover, blood flow is not constant
along the shunt but depends on various concomitant factors, such as
the tube diameter, the presence of kinking and the "driving force"
in the proximal aorta.27
advantage of left heart bypass is the possibility of connecting a heat
exchanger to the circuit, thus allowing homeothermia/moderate hypothermia
to be achieved during surgery. On completion of aortic reconstruction,
prior to decannulation, this exchanger also enables the patient's physiological
temperature to be restored, thus diminishing the risk of coagulation
disorders and cardiac arrhythmia.
assistance is generally supported by a centrifugal pump, unless the
patient has undergone full heparinization. First described by Rafferty
& Kletschka28 in 1968 and introduced
into clinical practice in 1975, this kinetic pump offers several advantages
compared to traditional methods (Roller pump). The kinetic energy transmitted
to the blood is generated by the high-speed rotation of a series of
coaxial cones, producing a hematic vortex identical to a cyclone. The
Bio Console motor interacts with a magnet fitted to the base of the
cones which regulates the speed of revolution: increased velocity means
an increased centrifugal force of blood and hence an increased output.
The cones are designed to minimize the traumatic lyses of red blood
cells. Owing to the dynamics generating the hematic vortex, any potentially
thrombogenic element is trapped at the tip of the cones (the eye of
the cyclone), thus preventing its emission into the circulation. Lastly,
the circuit is fitted with a filter thus guaranteeing the complete safety
of the system.
the preliminary results were often divergent in small series of patients,29-33
it is now clear that, if executed using left heart bypass and sequential
aortic cross-clamping, distal aortic perfusion (DAP) exerts a protective
effect on the kidneys and spinal cord in the event of prolonged aortic
experience confirms that the use of DAP in the form of left heart bypass
with Biomedicus pump and sequential cross-clamping, associated with
cerebrospinal fluid drainage, allowed us to achieve complication rates
comparable to international experience.
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