SIMULTANEOUS TOTAL AORTIC REPLACEMENT FROM VALVE TO BIFURCATION - EXPERIENCE WITH 21 CASES

From June 1985 to December 1991, 21 patients (12 men and 9 women; mean age, 60 years) underwent total simultaneous aortic replacement that extended from the valve to the bifurcation. The causes of the diseased aorta were: medial degeneration with total aortic dilatation or multiple aneurysms (n = 7) and either acute (n = 4) or chronic (n = 10) dissection. Clinical evaluation and investigation in all patients consisted of computed tomography and magnetic resonance imaging as well as angiography. Only patients with combined thoracic and abdominal emergencies were selected, and these comprised worsening of cardiac conditions resulting from aortic regurgitation, and rapid dilatation of the ascending aorta and arch with impending rupture in conjunction with ischemia of the abdominal viscera, kidney, or either leg. The surgical technique consisted of inducing deep hypothermia by means of femoral vein-femoral artery cardiopulmonary bypass. During the cooling time, the aortic root was replaced under cardioplegia. Once lowering of the body temperature attained electroencephalographic silence, circulation was stopped and the aorta was replaced from the arch to the bifurcation. Circulation and rewarming were resumed only after the operation was completed. In our most recent patient, the operating time was reduced by opening the thoracic and the abdominal incisions during cooling; the cardioplegic solution was not injected but, instead, the myocardium was cooled down along with the whole body. In these patients, the hypothermy at electroencephalographic silence ranged from 14-degrees to 19-degrees-C. Only once did the cerebral ischemia-exceed 60 minutes. In 14 patients, the intercostal arteries were reconnected. All patients survived operation. Three (14.2%) died within 1 month, and neurologic disturbances of the lower extremities, which affected 3 patients, disappeared within 2 months. Follow-up in the 18 surviving patients ranged from 2 months to 7 years. There were two late deaths after 4 and 6 years, and the actuarial 5-year survival estimate, including the operative mortality, was 72%. Combined emergencies of the thoracic and abdominal aorta were the indication for this operation. Considering the acceptable surgical risk involved, we think that elective indications should also be considered for such a procedure.