Sage Journals: Discover world-class research

Abstract

Forty-six patients who had had an elective repair of a descending thoracic aortic aneurysm were reviewed, in order to investigate the efficacy of support by a centrifugal pump on distal organ perfusion and spinal cord protection during cross-clamping of the thoracic aorta. Two concurrent groups were analysed: 36 patients (78%) were supported by left atriofemoral arterial bypass with a centrifugal pump and 10 (22%) had no distal circulatory support. No patient was fully heparinized. The demographic data and preoperative characteristics of the groups, including location and type of aneurysm, were similar. The mean(s.d.) duration of cross-clamping was 37.8(16) min in the centrifugal pump group and 42.3(21) min in the simple clamping group. Preoperative haemodynamic and laboratory data were similar in both groups. During cross-clamping, parameters of pH and blood urea varied but were better in the centrifugal pump group; changes from pre-intervention to early aortic cross-clamping time were not significant (pH, P< 0.0006; bases, P< 0.0003). Differences in creatinine values were caused mainly by the change from pre-intervention to the first postoperative day (P< 0.03); this continued throughout the hospital stay. The cerebrospinal fluid pressure measurement indicated a significant difference in time change (P< 0.0001) and mean level over time (P< 0.0002): levels were significantly lower in the centrifugal pump group throughout aortic cross-clamping. Three patients in the simple clamping group and none in the centrifugal pump group (P< 0.02) required cerebrospinal fluid drainage. Paraplegia occurred in one patient (3%) in the centrifugal pump group and in one (10%) in the simple clamping group (P= n.s.). The overall in-hospital mortality rate was 9%, with 71% of all deaths occurring in patients who had an emergency repair of the aneurysm. The cumulative 5-year survival rate was 72% in the centrifugal pump group and 84% in the simple clamp group (P = n.s.). The results confirm that patients offered centrifugal pump support are better stabilized metabolically, suggesting that spinal cord perfusion is improved.

Keywords

descending thoracic aorta aneurysm left-left centrifugal pump bypass distal perfusion

Get full access to this article

View all access options for this article.

References

King

Shumacher

Jr . Mechanical by-pass during thoracic aortic cross-clamping. J Thorac Surg 1957; 34: 485–99.

Hug

Taber

. Bypass flow requirements during thoracic aneurysmectomy with particular attention to the prevention of left heart failure. J Thorac Cardiovasc Surg 1969; 57: 203–13.

Symbas

Pfalender

Drucker

Cross-clamping of the descending aorta: hemodynamic and neurohumoral effects. J Thorac Cardiovasc Surg 1985; 85: 300–5.

Blaisdell

Cooley

. The mechanism of paraplegia after temporary thoracic aortic occlusion and its relationship to spinal fluid pressure. Surgery 1962; 51: 351–5.

Katz

Blackstone

Kirklin

. Incremental risk factors tor spinal cord injury following operation for acute aortic traumatic transection. J Thorac Cardiovasc Surg 1981; 81: 669–74.

Livesay

Cooley

Ventemiglia

Surgical experience in descending thoracic aneurysmectomy with and without adjuncts to avoid ischemia. Ann Thorac Surg 1985; 39: 37–46.

Wadouh

Arndt

Oppermann

The mechanism of spinal cord injury after simple and double aortic cross-clamping. J Thorac Cardiovasc Surg 1986; 92: 121–7.

Sturm

Bolliar

Luxemberg

Risk factors for the development of renal failure following the surgical treatment of traumatic aortic rupture. Ann Thorac Surg 1987; 43: 425–7.

Kouchoukos

Lell

Karp

Hemodynamic effect of aortic clamping and decompression with a temporary shunt for resection of the descending thoracic aorta. Surgery 1979; 85: 25–30.

10.

Jex

Schaff

Piehler

Early and late results following repair of dissections of the descending thoracic aorta. J Vasc Surg 1986; 3: 226–37.

11.

Cartier

Orszulak

Pairolero

Schaff

. Circulatory support during cross-clamping of the descending aorta. Evidence of improved perfusion. J Thorac Cardiovasc Surg 1990; 99: 1038–47.

12.

Olivier

Maher

George

Park

Burkholder

Magovern

. Use of the Bio-Medicus centrifugal pump in traumatic tears of the descending aorta. Ann Thorac Surg 1984; 38: 586–91.

13.

Diehl

Payne

Rastegar

Cleveland

. Arterial bypass of the descending thoracic aorta with the Biomedicus centrifugal pump. Ann Thorac Surg 1987; 44: 422–3.

14.

Miyamoto

Ueno

Wada

Kimoto

. A new and simple method of preventing spinal cord damage following temporary occlusion of the thoracic aorta by draining the cerebrospinal fluid. J Cardiovasc Surg (Torino) 1960; 1: 188–97.

15.

McCullough

Hollier

Nugent

. Paraplegia after thoracic aortic occlusion: influence of cerebrospinal fluid drainage. Experimental and early clinical results. J Vasc Surg 1988; 7: 153–60.

16.

Griffiths

Pitts

Crawford

Trench

. Spinal cord compression and blood flow. The effect of raised cerebrospinal fluid pressure on spinal cord flow. Neurology 1978; 28: 1145–51.

17.

Roberts

Nora

Hughes

Cardiac and renal responses to cross-clamping of the descending thoracic arota. J Thorac Cardiovasc Surg 1983; 86: 732–41.

18.

Stavens

Hashim

Hammond

. Optimal methods of repair of descending thoracic aortic transection and aneurysm. Am J Surg 1983; 145: 508–13.

19.

Hilgenberg

Rainer

Sadler

Jr . Aneurysm of the descending thoracic aorta: replacement with the use of shunt or bypass. J Thorac Cardiovasc Surg 1981; 85: 98–104.

20.

Donahoo

Brawley

Gott

. The heparin-coated vascular shunt for thoracic aortic and great vessel procedures: a ten-year experience. Ann Thorac Surg 1977; 23: 507–13.

21.

Pett

Jr Wernly

J A

Akl

. Observations on flow characteristics of passive external aortic shunts. J Thorac Cardiovasc Surg 1987; 93: 447–53.

22.

DeBakey

Cooley

Crawford

Morris

Jr . Aneurysm of the thoracic aorta: analysis of 170 patients treated by resection. J Thorac Cardiovasc Surg 1958; 36: 393–7.

23.

Livesay

Cooley

Ventemiglia

Surgical experience in descending thoracic aneurysmectomy with and without adjuncts to avoid ischemia. Ann Thorac Surg 1985; 39: 37–46.

24.

DeBakey

McCollum

Graham

. Surgical treatment of aneurysm of the descending aorta. J Cardiovasc Surg (Torino) 1978; 19: 571–6.

25.

Crawford

Walker

Saleh

Norman

. Graft replacement of aneurysm in descending thoracic aorta: results without bypass or shunting. Surgery 1981; 89: 73–85.

26.

Crawford

Mizray

Hess

Coselli

Safi

Patel

. The impact of distal aortic perfusion and somatosensory evoked potential monitoring on prevention of paraplegia after aortic aneurysm operation. J Thorac Cardiovasc Surg 1988; 95: 357–67.

27.

Cunningham

Jr . Discussion of Crawford et al. (reference 26).

28.

Ergin

Galla

Lansman

Taylor

Griepp

. Distal perfusion methods for surgery of the descending aorta. In: Loop

, ed. Seminars in Thoracic and Cardiovasscular Surgery, Part II. ———: WB Saunders, 1991; vol. 3; 4: 293–9.

29.

Pontius

Brokman

HLR

Hardy

The use of hypothermia in the prevention of paraplegia following temporary aortic occlusion: experimental observations. Surgery 1986; 36: 33–8.

30.

Connoly

Kountz

Boyd

. Left heart bypass: experimental and clinical observations on its regulation with particular reference to maintenance of maximal renal blood flow. J Thorac Cardiovasc Surg 1962; 44: 577–89.

31.

Carlson

Karp

Kouchoukos

. Surgical treatment of aneurysm of the descending thoracic aorta: an analysis of 85 patients. Ann Thorac Surg 1983; 35: 58–69.

32.

Kouchoukos

Lell

Karp

Samuelson

. Hemodynamic effect of aortic clamping and decompression with a temporary shunt for resection of the descending thoracic aorta. Surgery 1979; 85: 25–30.

33.

Roberts

Nora

Hughes

Cardiac and renal responses to cross-clamping of the descending thoracic aorta. Ann Thorac Surg 1984; 38: 586–91.

34.

Crawford

Safi

. Thoracoabdominal aortic aneurysm: preoperative and intraoperative factors determining immediate and long-term results in 605 patients. J Vasc Surg 1986; 3: 389–404.

35.

Kieffer

Thierry

Chiras

Preoperative spinal cord arteriography in aneurysmal disease of the descending thoracic and thoracoabdominal aorta: preliminary results in 45 patients. Ann Vasc Surg 1989; 3: 34–46.

36.

Cunningham

Jr Laschinger

J C

Spencer

. Monitoring of somatosensory evoked potentials during surgical procedures on the thoracoabdominal aorta. Clinical observations and results. J Thorac Cardiovasc Surg 1987; 94: 275–85.

37.

Laschinger

Cunningham

Jr Baumann

Monitoring of SEP during surgical procedures on the thoracoabdominal aorta: intraoperative identification of vessels critical to spinal cord blood supply. J Thorac Cardiovasc Surg 1987; 94: 266–70.

38.

Svensson

Von Ritter

Groeneveld

Crossclamping of the thoracic aorta: influence of aortic shunts, papaverine, calcium channel blockers, allopurinol, and superoxide dismutase on spinal cord blood flow and paraplegia in baboons. Ann Surg 1986; 204: 38–47.

39.

Kazui

Komatsu

Yokoama

. Surgical treatment of aneurysm of the thoracic aorta with the aid of partial cardiopulmonary bypass: an analysis of 95 patients. Ann Thorac Surg 1987; 43: 622–7.

40.

Neville

Cox

Leininger

Resection of the descending thoracic aorta with femoral vein to femoral artery oxygenation perfusion. J Thorac Cardiovasc Surg 1968; 56: 39–42.

41.

Kouchoukos

Wareing

Izumoto

Elective hypothermic cardiopulmonary bypass and circulatory arrest for spinal cord protection during operations on the thoracoabdominal aorta. J Thorac Cardiovasc Surg 1990; 99: 659–64.

42.

Kouchoukos

. Spinal cord ischemic injury: is it preventable? In: Loop

, ed. Seminars in Thoracic and Cardiovascular Surgery, Part II. ——: WB Saunders, 1991, vol. 3; 4: 300–5.

43.

Lazorthes

Qouaze

Zadeh

Santini

Lazorthes

Burdin

. Arterial vascularization of the spinal cord. Recent studies on the anastomotic substitution pathways. J Neurosurg 1971; 35: 235–41.

44.

Blaisdell

FEW

Cooley

. The mechanism of paraplegia after temporary thoracic aortic occlusion and its relationship to spinal fluid pressure. Surgery 1962; 51: 351–5.

45.

Boewr

Murray

Gloviczky

Yaksh

Hollier

Pairolero

. Effects of thoracic aortic occlusion and cerebrospinal fluid drainage on regional spinal cord blood flow in dogs: correlation with neurologic outcome. J Vasc Surg 1988; 9: 135–44.

46.

Gelman

Reves

Fowler

Samuelson

Lell

Smith

. Regional blood flow during cross-clamping of the thoracic aorta and infusion of sodium nitroprusside. J Thorac Cardiovasc Surg 1983; 85: 287–91.

Descending Thoracic Aorta Aneurysmectomy: Left-Left Centrifugal Pump versus Simple Clamping Technique

Abstract

Keywords

Get full access to this article

References