Surgical Treatment of Thoracoabdominal Aortic Aneurysm

Kim, Kyung Hwan; Ahn, Hyuk

Abstract

BACKGROUND: Thoracoabdominal aortic aneurysms are very extensive disease entity and in the aspect of visceral organ and spinal cord protection, they still have high operative morbidity and mortality. We reviewed the operative results, complication rates, and mortality rates. MATERIAL AND METHOD: From Jan 1990 to Dec 1999, there were 38 patients with thoracoabdominal aortic aneurysms. We performed a retrospective study of the medical chart reviews. RESULT: Male to female ratio was 22:16, and mean age was 46.2 +/-12.3 years. According to the classification of thoracoabdominal aortic aneurysms by Crawford, there were were 13 patients in type I (34.2%), 19 patients in type II(50%), 4 patients in type III (11%), and 2 patients in type IV (4.8%) patients. The most common underlying diseases were chronic aortic dissection (29 cases, 76.3%) and Marfan syndrome (9 cases, 23.7%). Distal aortic perfusion was performed in 35 cases, and, among them, partial cardiopulmonary bypass was done in 31 cases and left atrium to femoral artery bypass was done in 4 cases. We used profound hypothermic total circulatory arrest in 4 of the 31 patients who underwent partial cardiopulmonary bypass. We did selective visceral perfusion during aorta clamping. The maximal diameter of aortic aneurysms was 8.2 +/-2.4 cm, and aneurysmal rupture occurred in 11 cases(28.9%). We performed aorta replacement using sequential clamping technique. We anastomosed Adamkiewicz arteries which were located between the T8 to T 12 levels and have relatively larger diameter and back-bleeding. Three early deaths occurred and the causes were cardiopulmonary bypass weaning failure in two cases and sudden hypotension with metabolic acidosis in one case. Early complications were hoarseness (5 cases), bleeding(5 cases), wound infection(3 cases) and long-term ventilatory care (3 cases). Paraplegia occurred in 2 cases and in 1 of them, we could not perform intercostal anastomoses due to severe aortic wall calcification. We traced 35 patients for 103.1 +/-6.1 months. Cumulative survival rates were 93.8% in 2 years, 86.1% in 5 years and 80.7% in 8 years. During the follow-up period, we observed 4 late deaths and the causes were 1 aortoesophageal fistula and 1 aneurysmal rupture in left common carotid artery, and 2 unknown. Late complications were abdominal aortic aneurysms (2 cases), ascending aorta and aortic root dilatation(1 case), aortopleural fistula (1 case), incisional hernia (1 case) and retrograde ej aculation (1 case).
CONCLUSION
Our technique described here provides substantial protection against paraplegia. Furthermore, it allows complex operations to be performed on the thoracoabdominal aorta to be performed with acceptable morbidity and mortality.