Eur J Cardiothorac Surg 2000;18:611-612
© 2000 Elsevier Science NL
A simple method to correct aortic tube graft kinking without cardiopulmonary by-pass and aortic clamping
Giuseppe F. Zattera,
Guglielmo M. Actis Dato,
Stefano Del Ponte,
Giuseppe A. Poletti
Centro di Cardiochirurgia, Ospedale Motinette, Torino, Italy
Received 31 May 2000;
received in revised form 20 July 2000;
accepted 15 August 2000.
Corresponding author. Ospedale Molinette, V. le XXV Aprile 62, 10133, Torino, Italy
e-mail: raft56{at}infinito.it
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Abstract
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A method for correcting the tube kinking after ascending aortic replacement for acute dissection is described. Its main advantage is the no need for cardiopulmonary by-pass (CPB) and aortic clamping to solve the problem.
Key Words: Kinking • Surgery • Aortic dissection
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1. Introduction
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The surgical correction of acute type I aortic dissection usually requires tube replacement of the ascending aorta with commissural resuspension. In these cases it is frequently difficult to precisely evaluate the length of the tube with the heart flaccid and empty. As a consequence it is not uncommon to see various degrees of tube kinking after weaning of cardiopulmonary by-pass (CPB), especially in patients with very enlarged hearts, with the potential for ascending aortic obstruction. Here we describe a simple method to correct tube kinking which does not require resuming CPB and aortic clamping, with obvious advantages.
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2. Case description
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A 45-year-old man was admitted for an acute type I aortic dissection. At operation we replaced the ascending aorta and arch using deep hypotermic circulatory arrest for the distal correction and moderately hypothermic CPB and crystalloid cardioplegia for the proximal tube anastomosis.
After rewarming, we weaned CPB with important inotropic support. At this time became evident that the tube was somewhat longer than expected and severely kinked. We then tried, successfully, to solve the kinking with the technique described below (Figs. 1 and 2) .
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Fig. 1. Tube kinking resulting from a too long small curvature of the tube. 4/0 Prolene sutures with pledgets are passed from inside-out along the medial aspect of the tube.
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Fig. 2. The sutures are shortened until the desired length is achieved and tied, eliminating the kinking.
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Two 4/0 Prolene sutures with Teflon felt pledgets were passed, 1 cm apart from each other, horizontally in an inside-out fashion along the small curvature of the tube, starting 2 cm above the proximal anastomosis and extending to the undersurface of the arch. The sutures were than progressively shortened until the desired profile of the small curvature was achieved without residual tube kinking and tied. The arterial pressure suddenly increased, suggesting that the kinking was probably obstructing the flow in the ascending aorta. Postoperative echocardiogram (ECHO) revealed a trivial residual aortic regurgitation without tube kinking.
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3. Discussion
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The correction of acute aortic dissection still remains one of the most demanding surgical procedures. Contributing factors to the high morbidity and mortality rate are the long pump time and the phase of hypothermic circulatory arrest used for the open distal repair. So far it is desirable, when possible, to shorten these times as much as possible.
A possible complication of graft implantation is kinking of the tube, because it is often difficult to precisely assess the correct length and diameter of the prosthesis [1] during aortic clamping. As a consequence, sometime a kinking of the tube can produce various degrees of aortic obstruction [2]. The polytetrafluoroethylene (PTFE) seems to be more at risk than Dacron of kinking especially in the smaller sizes [3].
Our technique has the advantage of avoiding an additional period of cardiopulmonary by-pass and the myocardial ischemia due to aortic cross clamping. Moreover, this method seems even more precise because it allows the surgeon to adjust the length of the tube in physiologic conditions, – i.e. with the heart beating and off CPB. With cardioplegia, in fact, there is the potential risk for over correction – i.e. over shortening the tube – which could lead to excessive anastomotic tension and bleeding.
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References
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- Kohyama M., Ishihara H., Uchida N., Shibamura H., Kamimatsuse A. Short-term results of leaving elephant trunk in type A aortic dissection. Nippon Kyobu-Geka Gakkai Zasshi 1997;45:1208-1212.
- Waneck R., Polterauer P. Sonographic studies of the aorta after prosthetic replacement (follow-up of 112 patients). Wien Klin Wochenschr 1985;97:274-282.[Medline]
- Sottiurai V.S., Batson R.C. Technique to prevent aortic anastomotic bleeding and kinking with bifurcated PTFE grafts. Eur J Vasc Surg 1991;5:577-579.[Medline]
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Abstract
1. Introduction
