title: Does cross-clamping the arch increase the risk of descending thoracic and thoracoabdominal aneurysm repair?
abstract: BACKGROUND
  Descending thoracic and thoracoabdominal aortic aneurysms may arise in the distal aortic arch. Repair of these aneurysms has been associated with increased morbidity and operative mortality. Complex surgical and endovascular techniques have reduced the risks for this cohort. We examined outcomes utilizing an approach based on simple cross-clamping of the arch.
  
  
  METHODS
  From July 1997 to January 2004, 272 consecutive patients had aneurysm repair through the left chest. Twenty-nine requiring profound hypothermic circulatory arrest (PHCA) were excluded. Two hundred and forty-three were divided into two groups: group I (n = 60) had distal arch involvement and required cross-clamping proximal to the left subclavian artery. Group II (n = 183) were cross-clamped distal to the subclavian. Adjuncts for neurologic and renal protection were utilized as needed.
  
  
  RESULTS
  In-hospital mortality for all 243 patients was 3.7%. There was no difference in mortality between groups (I, 3.3% vs II, 3.8%). Group I patients also had similar rates of paraplegia (I, 0% vs II, 2.2%), stroke (I, 1.2% vs II ,1.1%), and renal failure (I, 1.7% vs II, 5.5%). Group I patients had significantly more recurrent nerve palsies (I, 33% vs II, 4.9%) although this did not translate into a higher incidence of respiratory failure.
  
  
  CONCLUSIONS
  Repair of thoracic aneurysms arising in the distal arch can be repaired with a technique based on simple cross-clamping without an increase in mortality or major neurologic injury. Recurrent nerve palsy is much more common with this approach but is well-tolerated without increasing the need for tracheostomy.
authors.affiliation: Department of Cardiothoracic Surgery, Weill Medical College of Cornell University, New York, New York 10021, USA. lngirard@med.cornell.edu
authors.forename: Leonard N
authors.initials: LN
authors.lastname: Girardi
authors.forename: Karl H
authors.initials: KH
authors.lastname: Krieger
authors.forename: Charles A
authors.initials: CA
authors.lastname: Mack
authors.forename: Leonard Y
authors.initials: LY
authors.lastname: Lee
authors.forename: Anthony J
authors.initials: AJ
authors.lastname: Tortolani
authors.forename: O Wayne
authors.initials: OW
authors.lastname: Isom
mesh_terms: D058186:Acute Kidney Injury / Q000453:epidemiology / Q000209:etiology; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D000714:Anastomosis, Surgical; D001013:Aorta, Thoracic / Q000473:pathology / Q000601:surgery; D017544:Aortic Aneurysm, Abdominal / Q000473:pathology / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000473:pathology / Q000601:surgery*; D015331:Cohort Studies; D003250:Constriction; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D010264:Paraplegia / Q000453:epidemiology / Q000209:etiology; D011183:Postoperative Complications / Q000453:epidemiology / Q000209:etiology* / Q000401:mortality; D012092:Replantation; D012189:Retrospective Studies; D012306:Risk; D020521:Stroke / Q000453:epidemiology / Q000209:etiology; D013348:Subclavian Artery / Q000601:surgery; D016896:Treatment Outcome; D014826:Vocal Cord Paralysis / Q000453:epidemiology / Q000209:etiology