Surgical Treatment of the Distal Aortic Arch Aneurysm Using Selective Cerebral Perfusion

Replacement of the distal aortic arch extending to the descending thoracic aorta is a challenging operation because of the location of the aneurysm between the upper mediastinum and left thorax. The objectives of this study were to examine the efficacy of modifications to myocardial protection, selective cerebral perfusion (SCP), and the operative method. Between January 1987 and December 1998 a total of 74 patients with distal aortic arch aneurysm underwent repair of the aortic arch and descending thoracic aorta. The ages of the patients ranged from 55 to 80 years (mean 69 years). All patients underwent median sternotomy, and 13 required extension into the fourth or fifth intercostal space. All cases were operated on with the aid of hypothermic cardiopulmonary bypass and SCR Complete replacement of the aortic arch extending to the descending thoracic aorta was performed in 53 patients and partial replacement of the aortic arch extending to the descending thoracic aorta in 20 patients. In addition, 12 patients underwent concomitant coronary aorta bypass grafting. The elephant trunk method was performed in three patients who required a secondary operation. Two patients underwent secondary replacement of the thoracoabdominal aorta. The average duration of cardiopulmonary bypass was 266 min and that of myocardial ischemia 118 min. The average duration of SCP was 129 min at an average esophageal temperature of 19.3°C. There were nine hospital deaths (12.1%). Hospital mortality was 14.6% in patients during 1987-1995 and 5.3% during 1996-1998. Postoperative cerebrovascular accidents occurred in four patients (5.4%), two of whom survived with hemiplegia; the other two died owing to deep coma. There have been no cerebrovascular accidents since 1995. Replacement of the aortic arch extending to the descending thoracic aorta using SCP is a safe procedure, with acceptable hospital mortality and incidence of cerebrovascular accidents.