Repair of Extensive Thoracoabdominal Aortic Aneurysm with a Tetrafurcate Graft: Midterm Results of 63 Cases
DOI:
https://doi.org/10.1532/HSF98.20091081Abstract
Objective: The objective is to present a method for maintaining the spinal cord blood supply and our midterm results for using a tetrafurcate graft in extensive thoracoabdominal aortic aneurysm (TAAA) repair.
Methods: From August 2003 to October 2007, we used a tetrafurcate graft to perform repairs to TAAAs of Crawford extent II in 63 consecutive patients. The mean age of this group of patients was 39.98 ± 10.62 years, and 46 (73%) of them were male. All of the procedures were performed under profound hypothermia with a short interval of circulatory arrest. T6 to T12 intercostal arteries were reconstructed as a "neo-intercostal artery" (N-IA) and were connected to an 8-mm sidearm of the graft to maintain the spinal cord blood supply. Visceral arteries were joined into a patch and were anastomosed to the end of the main graft. The left renal artery was anastomosed to an 8-mm sidearm or joined to the patch. The other 10-mm sidearms were anastomosed to iliac arteries.
Results: With 100% follow-up, the early-mortality rate was 7.94%. The incidence of cerebral complications was 9.52%. Temporary paraplegia was observed in 2 patients, and paraparesis occurred in 1 patient. Pulmonary complication was the most common morbidity in this group (25.40%). Two patients with Marfan syndrome had N-IA artery pseudoaneurysms during follow-up. The mean survival time of this group was 50.64 ± 2.13 months, with survival rates of 92.06% after 1 year, 88.38% after 2 years, and 86.11% after 3 years.
Conclusion: The N-IA may play an important role in spinal cord protection, and N-IA pseudoaneurysm should be avoided in Marfan syndrome patients. The use of a tetrafurcate graft is a reliable method for TAAA repair, with satisfactory midterm results.
References
Bavaria JE, Woo YJ, Hall RA, Carpenter JP, Gardner TJ. 1995. Retrograde cerebral and distal aortic perfusion during ascending and thoracoabdominal aortic operations. Ann Thorac Surg 60:345-53.nCina CS, Abouzahr L, Arena GO, Laganà A, Devereaux PJ, Farrokhyar F. 2004. Cerebrospinal fluid drainage to prevent paraplegia during thoracic and thoracoabdominal aortic aneurysm surgery: a systematic review and meta-analysis. J Vasc Surg 40:36-44.nCoselli JS, Bozinovski J, Cheung C. 2008. Hypothermic circulatory arrest: safety and efficacy in the operative treatment of descending and thoracoabdominal aortic aneurysms. Ann Thorac Surg 85:956-64.nCoselli JS, LeMaire SA, Conklin LD, Koksoy C, Schmittling ZC. 2002. Morbidity and mortality after extent II thoracoabdominal aortic aneurysm repair. Ann Thorac Surg 73:1107-15; discussion 1115-6.nCoselli JS, LeMaire SA, Miller CC 3rd, et al. 2000. Mortality and paraplegia after thoracoabdominal aortic aneurysm repair: a risk factor analysis. Ann Thorac Surg 69:409-14.nCrawford ES. 1974. Thoraco-abdominal and abdominal aortic aneurysm involving renal, superior mesenteric, and celiac arteries. Ann Surg 179:763-72.nCreech O Jr, DeBakey ME, Morris GC Jr. 1956. Aneurysm of thoracoabdominal aorta involving the celiac, superior mesenteric, and renal arteries: report of four cases treated by resection and homograft replacement. Ann Surg 144:549-73.nDardik A, Perler BA, Roseborough GS, Williams GM. 2001. Aneurysm expansion of the visceral patch after thoracoabdominal aortic replacement: an argument for limiting patch size. J Vasc Surg 34:405-10.nDe Paepe A, Devereux RB, Dietz HC, Hennekam RC, Pyeritz RE. 1996. Revised diagnostic criteria for the Marfan syndrome. Am J Med Genet 62:417-26.nEstrera AL, Miller CC 3rd, Huynh TT, Porat E, Safi HJ. 2001. Neurologic outcome after thoracic and thoracoabdominal aortic aneurysm repair. Ann Thorac Surg 72:1225-30; discussion 1230-1.nEtz CD, Di Luozzo G, Bello R, et al. 2007. Pulmonary complications after descending thoracic and thoracoabdominal aortic aneurysm repair: predictors, prevention, and treatment. Ann Thorac Surg 83:S870-6.nEtz CD, Halstead JC, Spielvogel D, et al. 2006. Thoracic and thoracoabdominal aneurysm repair: Is reimplantation of spinal cord arteries a waste of time? Ann Thorac Surg 82:1670-7.nFrank SM, Parker SD, Rock P, et al. 1994. Moderate hypothermia, with partial bypass and segmental sequential repair for thoracoabdominal aortic aneurysm. J Vasc Surg 19:687-97.nGilling-Smith GL, Worswick L, Knight PF, Wolfe JH, Mansfield AO. 1995. Surgical repair of thoracoabdominal aortic aneurysm: 10 years' experience. Br J Surg 82:624-9.nHagl C, Khaladj N, Karck M, et al. 2003. Hypothermic circulatory arrest during ascending and aortic arch surgery: the theoretical impact of different cerebral perfusion techniques and other methods of cerebral protection. Eur J Cardiothorac Surg 24:371-8.nJacobs MJ, Mess WH. 2003. The role of evoked potential monitoring in operative management of type I and type II thoracoabdominal aortic aneurysms. Semin Thorac Cardiovasc Surg 15:353-64.nKazui T. 2006. Invited commentary. Ann Thorac Surg 82:1677-8.nKouchoukos NT, Daily BB, Rokkas CK, Murphy SF, Bauer S, Abboud N. 1995. Hypothermic bypass and circulatory arrest for operations on the descending thoracic and thoracoabdominal aorta. Ann Thorac Surg 60:67-77.nKouchoukos NT, Masetti P, Castner CF. 2005. Use of presewn multiple branched graft in thoracoabdominal aortic aneurysm repair. J Am Coll Surg 201:646-9.nKouchoukos NT, Masetti P, Rokkas CK, Murphy SF, Blackstone EH. 2001. Safety and efficacy of hypothermic cardiopulmonary bypass and circulatory arrest for operations on the descending thoracic and thoracoabdominal aorta. Ann Thorac Surg 72:699-708.nLaffey JG, Boylan JF, Cheng DC. 2002. The systemic inflammatory response to cardiac surgery: implications for the anesthesiologist. Anesthesiology 97:215-52.nLombardi JV, Carpenter JP, Pochettino A, Sonnad SS, Bavaria JE. 2003. Thoracoabdominal aortic aneurysm repair after prior aortic surgery. J Vasc Surg 38:1185-90.nMauney MC, Tribble CG, Cope JT, et al. 1996. Is clamp and sew still viable for thoracic aortic resection? Ann Surg 223:534-43.nSafi HJ, Miller CC 3rd, Subramaniam MH, et al. 1998. Thoracic and thoracoabdominal aortic aneurysm repair using cardiopulmonary bypass, profound hypothermia, and circulatory arrest via left side of the chest incision. J Vasc Surg 28:591-8.nSchepens MA, Defauw JJ, Hamerlijnck RP, Vermeulen FE. 1995. Use of left heart bypass in the surgical repair of thoracoabdominal aortic aneurysms. Ann Vasc Surg 9:327-38.nVerdant A. 1992. Descending thoracic aortic aneurysms: surgical treatment with the Gott shunt. Can J Surg 35:493-6.nWoo EY, Mcgarvey M, Jackson BM, Bavaria JE, Fairman RM, Pochettino A. 2007. Spinal cord ischemia may be reduced via a novel technique of intercostal artery revascularization during open thoracoabdominal aneurysm repair. J Vasc Surg 46:421-6.n
