Hybrid procedure to treat aortic arch aneurysm combined with aortic arch coarctation and left internal carotid artery aneurysm (Case Report)

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Abstract

Aortic arch aneurysm is a rare condition but carries a high risk of rupture. We report one case of aortic arch aneurysm combined with aortic arch coarctation and left internal carotid artery aneurysm, which is extremely rare. Left internal carotid artery aneurysm resection and revascularization, carotid and carotid graft bypass combined with endovascular stent graft and embolization with coils were successfully performed. There were no any complaints and complications at 8 months follow-up. The follow-up CTA demonstrated thrombus formation in the aneurysm lumen, no endoleak and the aortic arch and bypass graft were all patent. We feel that hybrid procedure may be a valuable therapeutic alternative when treating this type of lesion. However, long-term clinical efficacy and safety have yet to be confirmed.

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Selective antegrade cerebral perfusion attenuates brain metabolic deficit in aortic arch surgery: a prospective randomized trial.

R. Harrington, M Faroqui, H Kaukuntla … (2004)

Aortic arch surgery has a high incidence of brain injury. This may in part be caused by a cerebral metabolic deficit observed after hypothermic circulatory arrest (HCA). We hypothesized that selective antegrade cerebral perfusion (SACP) would attenuate this phenomenon. In a prospective randomized trial, 42 adult patients were allocated to either HCA (22) or SACP. HCA occurred at a nasopharyngeal temperature of 15 degrees C and SACP at a corporeal temperature of 25 degrees C with cerebral perfusion at 15 degrees C. Paired arterial and jugular venous samples were taken before and after arrest. Continuous transcranial Doppler monitoring of middle cerebral artery velocity (MCAV) was performed. Neuropsychometric testing was performed preoperatively and at 6 and 12 weeks postoperatively. There were 3 hospital deaths (7.1%), 2 strokes (4.8%), and 6 episodes of transient neurological deficit (14.3%). From before to after arrest, jugular bulb pO2 changed by -21.67 mm Hg (26.4) in the HCA group versus +2.27 mm Hg (18.8) in the SACP group (P=0.007). Oxygen extraction changed by +1.7 mL/dL (1.3) in the HCA group versus -1 mL/dL (2.4) in the SACP group (P<0.001). MCAV increased by 6.25 cm/s (9.1) in the HCA group and 19.2 cm/s (10.1) in the SACP group (P=0.001). Incidence of neuropsychometric deficit at 6 weeks was 6/12 (50%) in HCA patients and 8/10 (80%) in SACP patients (P=0.2), and at 12 weeks was 6/16 (38%) in HCA patients and 4/11 (36%) in SACP patients (P=1). SACP attenuates the metabolic changes seen after HCA. Further studies are required to assess optimal perfusion conditions and clinical outcome.

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Antegrade cerebral perfusion with cold blood: a 13-year experience.

Jean Bachet, David Guilmet, Bertrand Goudot … (1999)

In 1986 we introduced the technique of antegrade selective perfusion of the brain with cold blood during surgery of the aortic arch. Between January 1984 and March 1998, 171 patients (118 males and 53 females) aged 25 to 83 years (mean 56.5 +/- 17), underwent replacement of the transverse aortic arch with the aid of cold blood antegrade selective perfusion. One hundred twenty two patients (71.3%) with chronic lesions were operated on electively; 49 patients (28.6%) were operated on urgently for acute aortic dissection (42 patients) or for a ruptured chronic aneurysm (7 patients). Fifty-one patients (29.8%) had previously undergone a surgical procedure on the thoracic aorta. Mean duration of cardiopulmonary bypass was 121 minutes (range: 65-248); mean duration of cerebral perfusion was 60 minutes (range: 15-90), and mean duration of systemic circulatory arrest circuit was 32 minutes (range: 10-57). The electroencephalogram, routinely recorded, showed disappearance of electrical activity in a mean of 9 minutes (range: 3-16) initial return of electrical activity after a mean of 12 minutes (range: 1-35) and normalization in a mean time of 66 minutes. All patients but 7 (4%) showed signs of normal awakening within 8 hours postoperatively. Six patients (3.5%) had fatal neurologic complications, and 16 patients (9.3%) had a non-fatal neurologic complications. Twenty-nine patients (16.9%) died during the postoperative hospital course. There was a significant difference between patients aged less than 60 years (9%) and patients older than 60 years (mortality rate 26.4%, p < 0.02). There was also a significant difference between patients undergoing an isolated replacement of the arch, and those in whom the replacement was extended to the descending aorta in whom mortality was 36.4% (chi2, p < 0.02). Lesion and gender had no significant influence on the outcome of the patients, nor had the duration of cardiopulmonary bypass, circulatory arrest, and cerebral perfusion. In particular, no correlation could be established between the duration of cerebral perfusion and the occurrence of neurologic complications. The clinical results obtained throughout this experience have demonstrated that selective antegrade cerebral perfusion with cold blood provides excellent protection during surgery of the transverse aortic arch. In addition, it avoids the use of deep hypothermia and prolonged cardiopulmonary bypass and does not limit the time allowed to perform the aortic repair. In our opinion it is the technique of choice, especially in frail patients or those requiring a long and difficult procedure.

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Arch and descending aortic aneurysms: influence of perfusion technique on neurological outcome.

S Westaby, T Katsumata, G. Vaccari (1999)

Although cannulation of the femoral artery is used routinely for thoracic aortic operations with hypothermic circulatory arrest, retrograde perfusion through the descending aorta carries the risk of cerebral malperfusion or embolism. We have, therefore, routinely used a central cannulation technique for distal arch and descending aortic operations since 1995. In this study, we compared neurological outcome in consecutive patients undergoing femoral versus ascending aortic perfusion for these aneurysms. Between 1987 and 1998, 61 patients underwent aortic resection with circulatory arrest, but without retrograde cerebral perfusion, for lesions of the aortic arch and descending aorta. Thirty-one patients had fusiform true aneurysms, 19 had aortic dissection and 11 had extensive saccular or false aneurysms. Thirty-two patients (52%) were perfused via the femoral artery (group A), and 29 patients (48%) from the ascending aorta (group B). Operative mortality and morbidity, and neurological outcome, were reviewed. There were no differences between the groups in mean age, pathology, abdominal and peripheral vascular disease, net perfusion time, or circulatory arrest time. There were four hospital deaths (three in group A and one in group B; P = 0.61), including one neurological death in group A, group A suffered a higher incidence of neurological events (nine patients: 28%) than group B (two patients: 7%; P = 0.03). Temporary focal neurological deficits occurred in both groups (two patients in group A, 6% and two patients in group B, 7%; P > 0.99), but permanent injury occurred exclusively in group A (seven patients: four with monoplegia, one with hemiplegia, and two with diffuse cerebral injury with one death; P = 0.01). Anterograde perfusion using a proximal aortic cannula provides a low risk of cerebral embolism and allows extensive aortic resection with low morbidity.

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Journal

Journal ID (nlm-ta): J Cardiothorac Surg

Journal ID (iso-abbrev): J Cardiothorac Surg

Title: Journal of Cardiothoracic Surgery

Publisher: BioMed Central

ISSN (Electronic): 1749-8090

Publication date Collection: 2014

Publication date (Electronic): 3 January 2014

Volume: 9

Page: 3

Affiliations

[1 ]Department of Vascular Surgery, the second affiliated hospital of Nanchang University, No 1#, Minde Road, Nanchang, China

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Publisher ID: 1749-8090-9-3

DOI: 10.1186/1749-8090-9-3

PMC ID: 3898389

PubMed ID: 24387673

SO-VID: bdcf5e42-cf3b-4dcd-81ff-018087ab3bd7

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This is an open access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Hybrid procedure to treat aortic arch aneurysm combined with aortic arch coarctation and left internal carotid artery aneurysm (Case Report)

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Most cited references 10

Selective antegrade cerebral perfusion attenuates brain metabolic deficit in aortic arch surgery: a prospective randomized trial.

Antegrade cerebral perfusion with cold blood: a 13-year experience.

Arch and descending aortic aneurysms: influence of perfusion technique on neurological outcome.

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