THORACIC AND THORACOABDOMINAL AORTIC-ANEURYSM REPAIR USING CARDIOPULMONARY BYPASS, PROFOUND HYPOTHERMIA, AND CIRCULATORY ARREST VIA LEFT SIDE OF THE CHEST INCISION

Purpose: Although some authors advocate hypothermic circulatory arrest for spinal cord protection in descending thoracic and thoracoabdomina l repair, this method has been associated with high morbidity and mort ality rates in other studies. The safety and effectiveness of this sur gical adjunct were evaluated. Methods Between February 1991 and April 1997, 409 patients underwent thoracic or thoracoabdominal aortic repai r. Because of an inability to gain proximal aortic control because of anatomic or technical difficulty, hypothermic circulatory arrest was u sed in 21 patients (4.9%). Thirteen patients were men, 8 were women, a nd the median age was 57 (range, 21 to 81 years). Four patients (19%) had Marfan's syndrome, and 1 had aortitis. Seven patients (33%) had ao rtic dissection (4 chronic type A, 2 chronic type B, 1 acute B), and 1 had aortic laceration. All but 6 patients had hypertension. Fifteen p atients (73%) were operated on for repair of the distal arch and desce nding thoracic aorta, 4 (19%) for repair of the distal arch and thorac oabdominal aorta, and 2 for repair of either the thoracoabdominal or d escending thoracic aorta alone. Surgery for 9 patients (43%) also incl uded bypass grafts to the subclavian or innominate arteries. Six opera tions (29%) were urgent. Results: The overall 30-day mortality rate wa s 29% (6 of 21 patients). Among urgent patients, the mortality rate wa s 50% (3 of 6 patients) versus 20% (3 of 15) for elective patients. Of the remaining 15 patients, renal failure occurred in 1 (7%) and heart failure in 2 (13%). Ten patients (67%) had pulmonary complications. E ncephalopathy occurred in 5 patients (33%) and stroke in 2 (13%), and spinal cord neurologic deficit developed in 2 (13%). The median recove ry was 28 days (range, 10 to 157 days). Conclusion: Hypothermic circul atory arrest did not reduce the incidence of deaths and morbidity to a rate comparable with our conventional methods. We recommend the judic ious application of this method in rare instances when proximal contro l is not feasible or catastrophic intraoperative bleeding leave the su rgeon with no other option.