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J Thorac Cardiovasc Surg 2004;128:669-676
© 2004 The American Association for Thoracic Surgery

Surgery for Acquired Cardiovascular Disease

Single-stage repair of extensive thoracic aortic aneurysms: Experience with the arch-first technique and bilateral anterior thoracotomy

Division of Cardiovascular and Thoracic Surgery, Missouri Baptist Medical Center, St Louis, Mo

Read at the Eighty-fourth Annual Meeting of The American Association for Thoracic Surgery, Toronto, Ontario, Canada, April 25-28, 2004.

Received for publication April 23, 2004; revisions received June 4, 2004; accepted for publication June 16, 2004.

^* Address for reprints: Nicholas T. Kouchoukos, MD, Cardiac, Thoracic and Vascular Surgery, Inc, 3009 N Ballas Rd, St Louis, MO 63131 (E-mail: ntkouch{at}aol.com).

BACKGROUND: Staged procedures for extensive aneurysmal disease of the thoracic aorta are associated with a substantial cumulative mortality (>20%) that includes hospital mortality for the 2 procedures and death (often from aortic rupture) in the interval between the 2 procedures. We have used a single-stage technique for operative repair of most or all of the thoracic aorta.

METHODS: Forty-six patients with extensive disease of the thoracic aorta were managed with a single-stage procedure by using a bilateral anterior thoracotomy and transverse sternotomy, hypothermic circulatory arrest, and reperfusion of the aortic arch vessels first to minimize brain ischemia. Thirty-one patients with chronic, expanding type A aortic dissections had previous operations for acute type A dissection (n = 22), aortic valve repair or replacement (n = 4), coronary artery bypass grafting (n = 4), or no previous operation (n = 1). The remaining 15 patients had degenerative aneurysms (n = 12) or chronic type B dissections with proximal extension (n = 3). The ascending aorta and aortic arch were replaced in all patients combined with resection of various lengths of descending aorta (proximal one third [n = 19], proximal two thirds to three quarters [n = 22], or all [n = 5]). Coronary artery bypass grafting, valve replacement, or both were performed concomitantly in 19 patients.

RESULTS: Hospital mortality was 6.5% (3 patients). Morbidity included reoperation for bleeding (17%), mechanical ventilation for more than 72 hours (42%), temporary tracheostomy (13%), and temporary renal dialysis (9%). No patient sustained a stroke. There have been 5 late deaths (3, 18, 34, 51, and 79 months postoperatively) unrelated to the aortic disease. Four patients have undergone successful reoperation on the aorta (false aneurysm [n = 1], endocarditis [n = 1], and progression of disease [n = 2]). Five-year survival was 75%.

CONCLUSION: The single-stage, arch-first technique is a safe and suitable alternative to the 2-stage procedure for repair of extensive thoracic aortic disease.

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