The Clinical Experience of the Aortic Arch Replacement in Acute Type A Aortic Dissection / 대한흉부외과학회지

BACKGROUND: The aortic arch replacement in an acute aortic dissection is technically demanding procedure that has a lot of postoperative morbidity and high mortality. The authors have applied several techniques of aortic arch replacement to overcome the risks of the procedure. Therefore we analysed the results of these techniques. MATERIAL AND METHOD: From March of 1996 to July of 2002, we performed 31 cases of the aortic arch replacement in the Stanford type A acute aortic dissection. There were 12 male and 19 female patients with 59.6+/-9.4 years of mean age. Among them 18 cases were treated with the hemiarch replacement and 13 cases with the total arch replacement. We approached the aortic arch through median sternotomy in all but 3 cases of Clamshell incision and applied the deep hypothermic circulatory arrest with retrograde cerebral perfusion. The associated procedures were 2 Bentall's procedures, an axillobifemoral bypass, a femorofemoral bypass and a carotid artery bypass. RESULT: The postoperative morbidities were 8 acute renal failures, 3 CNS complications, 2 low cardiac output syndromes, 2 malperfusion syndromes, and 2 deep wound infections. There were 4 cases of early hospital mortality which were from an acute renal failure, a postoperative bleeding, a low cardiac output syndrome, and a reperfusion syndrome. There were 3 cases of late hospital mortality which were from an acute renal failure, and 2 multiorgan failures. So the total mortality rate was 22.5%. There were 4 cases of late mortality after the discharge, which were form 2 cases of distal anastomotic rupture and 2 cases of intracranial hemorrhage. CONCLUSION: The hemiarch replacement has relatively shorter operative time and lower hospital mortality but higher late mortality than the total arch replacement. The total arch replacement needs more technically demanding procedure.

Role of the Inferior Thyroid Vein after Left Brachiocephalic Vein Division During Aortic Surgery / 대한흉부외과학회지

BACKGROUND: In aortic surgery, division and ligation of the left brachiocephalic vein(LBV) may improve exposure of the aortic arch but controversy continues about the safety of this division and whether a divided vein should be reanastomosed after arch replacement was completed. The safety of LBV division and the fate of the left subclavian venous drainage after LBV division were studied. MATERIAL AND METHOD: From November 1998 to January 2001, planned division and ligation of the LBV on the mid-line after median sternotomy was performed in 10 patients during the aortic surgery with the consideration of local anatomy and distal aortic anastomosis. Assessment for upper extremity edema and neurologic symptoms, measurement of venous pressure in the right atrium and left internal jugular vein, and digital subtraction venography(DSV) of the left arm were made postoperatively. RESULT: In 10 patients there was improvement in access to the aortic arch for procedures on the ascending aorta or aortic arch. The mean age of patients was 62 years(range 24 to 70). Follow-up ranged from 3 weeks to 13 months. One patient died because of mediastinitis from methicilline-resistant staphylococcus aureus strain. All patients had edema on the left upper extremity, but resolved by the postoperative day 4. No patient had any residual edema or difficulty in using the left upper extremity during the entire follow-up period. No patient had postoperative stroke. Pressure difference between the right atrium and left internal jugular vein was peaked on the immediate postoperative period(mean peak pressure difference = 25mmHg), but gradually decreased, then plated by the postoperative day 4. In all DSV studies left subclavian vein flowed across the midline through the inferior thyroid venous plexus. CONCLUSION: We conclude that division of LBV is safe and reanastomosis is not necessary if inferior thyroid vein, which is developed as a main bridge connecting the left subclavian vein with right venous system, is preserved.