Optimal methods of repair of descending thoracic aortic transection and aneurysms

The method for optimal protection of the spinal cord and viscera during surgical repair of aneurysms and acute disruptions of the descending thoracic aorta is controversial. We reviewed our experience with 50 consecutive patients who underwent such repairs between January 1968 and April 1982 to determine the safest method of protection. Thirty-two had acute transections, 9 had ruptured aneurysms, 6 had false aneurysms, and three had atherosclerotic aneurysms. Extracorporeal circulation was used in 21 patients with an average cross-clamp time of 67 minutes, a Gott shunt was used in 26 with an average cross-clamp time of 74 minutes, and no shunt was used in 3 patients with cross-clamp times of 20, 24, and 50 minutes. Paraplegia was significantly reduced with both extracorporeal circulation and the heparin-bonded Gott shunt; however, the former method was associated with a high incidence of postoperative bleeding in conjunction with systemic heparinization, and this, in turn, contributed to a high mortality, particularly in patients with traumatic transection who often had associated severe injuries. We believe that the Gott shunt provides the best protection, particularly in the setting of a training program where a relatively small number of these operations are performed and cross-clamp times may be prolonged.