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The Journal of Thoracic and Cardiovascular Surgery, Vol 96, 878-886, Copyright © 1988 by The American Association for Thoracic Surgery and The Western Thoracic Surgical Association
J Bachet, G Teodori, B Goudot, F Diaz, A el Kerdany, C Dubois, D Brodaty, P de Lentdecker and D Guilmet
In type A aortic dissection, the intimal disruption is located on or
extends to the transverse arch in about 20% of patients. Replacement of the
arch may then be necessary to avoid leaving an unresected, acutely
dissected aorta and to prevent bleeding, progression of aneurysm, rupture,
and ultimately reoperation or death. From 1970 to September 1987, 119
patients were operated on for type A acute dissection. Starting in January
1977, gelatin-resorcin-formaldehyde biologic glue was used in 91 patients
to reinforce the dissected tissues at the suture sites. Among these 119
patients, 26 (ages 32 to 76 years) underwent replacement of the transverse
aortic arch in addition to replacement of the ascending aorta. In 20
patients cerebral protection was achieved by profound hypothermia (16
degrees to 20 degrees C) associated with circulatory arrest (15 to 40
minutes, mean 27 minutes) during the distal anastomosis. In six patients
the carotid arteries were selectively perfused with cold blood (6 degrees
C) during moderate core hypothermia (28 degrees C) while cardiopulmonary
bypass was discontinued (19 to 34 minutes, mean 25 minutes) to allow the
prosthesis to be sutured without the distal aorta being cross-clamped.
Moderate hypothermia avoided the long rewarming time necessitated by
profound hypothermia. The hospital mortality rate was 34% (9/26). Two of
the 20 patients subjected to profound hypothermia and circulatory arrest
died during the operation and seven patients died of postoperative
complications. No deaths or major complication were observed in the other
six patients. Follow-up of the 17 survivors ranges from 3 to 90 months
(mean 39). One patient died 6 months after the operation of cerebral
hemorrhage. One patient is disabled by neurologic sequelae. Fifteen
patients are in good clinical condition (New York Heart Association class I
or II). Postoperative aortograms in 12 patients, and computed tomographic
scans in all, have shown a stable repair of the transverse arch in all
survivors but a persisting dissection of the descending aorta in 11 (70%).
Growing experience and improving results in emergency operations for type A
aortic dissection have led us to extend the replacement of the aorta to the
transverse arch whenever necessary. The gelatin-resorcin-formaldehyde glue
has proved to be an efficient adjunct. The best cerebral protection was
obtained in our experience by carotid perfusion with cold blood during
circulatory arrest at moderate core hypothermia.
ARTICLES
Replacement of the transverse aortic arch during emergency operations for type A acute aortic dissection. Report of 26 cases
Service de Chirurgie Cardio-vascularire, Hopital Foch, Universite Paris- Ouest, Suresnes, France.
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