Immediate results of surgical reconstruction of the aortic arch in patientswith proximal aortic dissection

Lyashenko M.M., Chernyavsky A.M., Alsov S.A., Sirota D.A., Khvan D.S.

Novosibirsk Scientific Research Institute for Circulatory Pathology named after Academician E.N. Meshalkin, Novosibirsk, Russia

Introduction. Despite obvious progress of surgical technologies in correction of proximal aortic pathology, improvement of methods of protection of the brain, one of the main problems of this direction remains the development of postoperative cerebral ischaemia of various degree of manifestation: strokes, transitory ischaemic attacks, or hypoxic encephalopathy. Of special interest is studying the group of patients presenting with aortic dissection, since this pathology may be accompanied by a wide variety of combinations of occlusive and stenotic lesions of the branches of the ascending portion of the aorta and aortic arch (coronary and brachiocephalic basins) by the detached intima.

Materials and methods. Over the period from 1999 to 2011, we operated on a total of 124 patients presenting with DeBakey type I aortic dissection. Of these, 194 were men (75.8%) and 30 (24.2%) women. The mean age amounted to 48.7±11.0 years. Etiologically prevailing were systemic atherosclerosis (91 patients, 73.4% of cases) and Marfan’s syndrome in 14 (11.3%) cases. In all patients operative intervention included reconstruction of the aortic arch according to one of the following techniques: prosthetic repair according to the type of an aggressive oblique anastomosis ("hemiarch repair") – 78 (62.9%) patients, prosthetic repair of the aortic arch using the multiple-branch prosthesis Plexus Vascutek – 37 (29.8%) patients, and nine patients underwent prosthetic repair of the aortic arch with a vascular graft with reimplantation of the brachiocephalic arteries with a single islet. The average duration of artificial circulation amounted to 230.1±70.0 minutes, the mean time of aortic occlusion was 167.2±44.2 minutes and that of circulatory arrest equalled 51.9±16.2 minutes. The brain during hypothermic circulatory arrest was protected according to the following techniques: 16 (12.9%) patients – isolated hypothermia with no cerebral perfusion, 76 (61.3 %) patients retrograde cerebral perfusion (RCP) through the superior vena cava, 23 (18.6%) patients – antegrade cerebral perfusion (ACP) and in 8 (6.5%) patients a combination of RCP + antegrade cerebral perfusion.

Conclusions. The early postoperative period showed a clear-cut interrelationship between the aetiology of aortic dissection and the onset of impairment of cerebral circulation. Increased incidence of strokes is promoted by more complicated and hence longer in time types of reconstruction of the aortic arch (islet technique, multiple-branch prosthesis). Antegrade cerebral perfusion had no statistically significant advantages over retrograde perfusion or perfusion-free hypothermic protection of the brain. Neither did the type of aortic dissection exert influence on cerebral circulation impairment (CCI). The presence of accompanying diseases did not determine the probability of the development of CCI in the early postoperative period. The analysis of the obtained findings revealed statistically significant relationship between the patient’s age and severity of CCI.

KEY WORDS: aortic aneurysm, thoracic aorta.

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