Total arch and descending thoracic aortic replacement by left thoracotomy

The hybrid treatment of transverse aortic arch pathologies with supraaortic debranching and endovascular repair is associated with significant morbidity and death and lacks long-term follow-up. The traditional two-stage open surgical approach to extensive arch and descending thoracic aneurysms carries a significant interval mortality rate. We report the results of a single-stage technique of total arch and descending thoracic aortic replacement by a left thoracotomy.

From January 1995 to February 2011, 426 patients underwent thoracic or thoracoabdominal aneurysm repair, of which a highly selected group of 27 patients underwent total arch replacement with descending thoracic or thoracoabdominal aortic replacement. All procedures were performed with hypothermic circulatory arrest and selective antegrade cerebral perfusion. Two patients required transverse division of the sternum. Two patients had emergency or urgent operations. Five patients had concomitant coronary artery bypass, and 1 had concomitant mitral valve replacement.

There were no hospital deaths, no cerebrovascular accidents, and one instance of transient spinal cord ischemia. Three patients had acute renal failure not requiring hemodialysis. Intubation in 5 patients exceeded 48 hours, and 1 patient needed tracheostomy. Two patients required reexploration for postoperative bleeding. Survival at 1, 3, and 5 years was 95%, 78%, and 73%, respectively.

Replacement of the total arch and descending thoracic aorta by a left thoracotomy provides excellent short-term and long-term results for the treatment of extensive arch and thoracic aortic pathology, without the need for a second-stage operation. Other cardiac pathologies, such as left-sided coronary disease and mitral valve disease, can be addressed concurrently.