Eur J Cardiothorac Surg 2002;21:97-99
© 2002 Elsevier Science NL
Ascending aortic replacement through right thoracotomy
Naotaka Motoyoshi*,
Katsuhiko Oda,
Yusuke Tsuru,
Koichi Tabayashi
Department of Cardiovascular Surgery, Graduate School of Medicine, Tohoku University, Sendai, Japan
Received 24 July 2001;
received in revised form 24 September 2001;
accepted 25 September 2001.
* Corresponding author. Tel.: +81-22-717-7222; fax: +81-22-717-7227
e-mail: paq{at}mva.biglobe.ne.jp
e-mail: naotaka5{at}hotmail.com
 |
Abstract
|
|---|
A 62-year-old woman with a history of esophageal resection and colon interposition with anterosternal subcutaneous tunnel required replacement of the ascending aorta due to dissecting aortic aneurysm. Preoperative three-dimensional computed tomography enabled us to reveal that right thoracotomy could offer an ascending aortic operation. The patient underwent successful operation under hypothermic circulatory arrest and the right anterolateral thoracotomy provided safe exposure of the diseased ascending aorta even when the suprasternal tunnel precluded conventional median sternotomy.
Key Words: Right thoracotomy • Ascending aortic aneurysm • Three-dimensional computed tomography
|
1. Introduction
|
|---|
Aortic surgery through a median sternotomy is occasionally contraindicated particularly when the anterosternal subcutaneous portion is occupied by a colon interposition after an esophageal resection. We report that a rare complicated case of right thoracotomy approach for ascending aortic replacement was confirmed feasible by three-dimensional computed tomography (3D-CT) even after colon interposition on anterosternum and the successful operation under circulatory arrest was performed through this approach.
|
2. Case report
|
|---|
A 62-year-old woman had had an aneurysm at the descending aorta for which she had undergone aortic replacement by tube graft in March 1998. After discharge, she had sudden bloody diarrhea with a spike fever. Aortic angiography revealed a pseudoaneurysm at the distal anastomosis. Aortic perforation into the esophagus or lung was suspected, therefore, we undertook the radical exclusion of the previous tube graft and a resection of the esophagus, in August 1998. Extra-anatomical bypass grafting from the ascending aorta to the abdominal aorta was also performed for visceral perfusion. Two months later, an anterosternal subcutaneous tunnel with colon interposition was performed. However, follow-up CT revealed an ascending aortic dissection, supposedly due to the previous partial clamping on aorta. The diameter of the dissecting aorta gradually increased to 6 cm in March 2000. 3D-CT demonstrated that a right thoracotomy, instead of median incision, might provide a good surgical view (Fig. 1). Lateral anterior thoracotomy approach for aortic surgery was reported only by Pretre et al. [1]. Svensson et al. reported that either replacement of aortic arch or aortic root was feasible with a malleable retractor in a limited ‘j-shaped’ minimal incision [2]. However clamping on the aortic arch would be difficult due to the more limited field than theirs. Echocardiography revealed normal cardiac function without aortic regurgitation and normal sizes of the Valsalva sinuses. For these reasons, graft replacement of the ascending aorta via right anterolateral thoracotomy under deep hypothermic circulatory arrest was planned.
View larger version (96K):
[in this window]
[in a new window]
|
Fig. 1. Preoperative three-dimensional X-ray computed tomographies revealing right anterior lateral view of thorax (A), and mediastinum removed lung, pericardium (B) and muscles including diaphragm (C). Roman numerals indicate the numbers of ribs. Small alphabet letters indicate anatomical identification; a, enlarged dissecting ascending aorta; b, right atrium; c, extra anatomical bypass; d, colon interposition with anterosternal subcutaneous tunnel. Dotted line indicates the 4th intercostal line.
|
|
The operation was performed in May 2000. A left decubitus position was chosen for a better surgical view. She had external defibrillation pads placed. The ascending aorta was exposed via right anterolateral thoracotomy incision through the 4th intercostal space. A flexible line to blow carbon dioxide gas in was fixed to the upper extent of the incision to allow for flooding of the incision with 10 l/min of carbon dioxide gas to reduce the risk of air embolism [2]. Cardiopulmonary bypass was established after cannulation of right subclavian artery, femoral artery and right atrium (Fig. 2), and a venting tube was placed in the left ventricle via the superior right pulmonary vein. Venous cannula placement was confirmed by transesophageal echocardiography. After cooled to 22°C under circulatory arrest, the diseased ascending aorta was opened circumferentially. An entry encircling 2/3 of the endothelium of the ascending aorta was found just proximal to the branched extra-anatomical bypass. The aortic wall was circumferentially reinforced with a felt strip using Gelatin-resorcinol-formaldehyde glue. Cardioplegic solution was invited through both antegrade selective and retrograde fashions. Selective cannulation to the right coronary artery ostium was difficult, however feasible. More extended surgical approach, such as replacement of aortic arch, would have been impossible as indicated in preoperative 3D-CT. Distal anastomosis was performed with unclamped technique. Then circulatory support was restarted after the new prosthesis clamped and rewarming was initiated. The interval of deep hypothermic circulatory arrest was 42 min. The proximal anastomosis was completed, and the clamp on the new prosthesis was removed after air evacuation. Extra-anatomical bypass graft was reimplanted in the new prosthesis during partial clamping. Thereafter cardiopulmonary bypass was removed uneventfully. The patient was transferred to the intensive care unit in a satisfactory condition. Extubation was performed on 2 POD. The patient left the intensive care unit on 3 POD and recovered without complication, and was discharged on 27 POD.
View larger version (31K):
[in this window]
[in a new window]
|
Fig. 2. That the cardiopulmonary bypass (CPB) circuit for our case of ascending aortic dissection after radical exclusion of descending aorta and extra-anatomical bypass grafting. CPB was established through the cannulation of right subclavian artery, right femoral artery, and right atrium via right femoral vein. Dashed line indicates the excluded descending aorta.
|
|
|
3. Discussion
|
|---|
A median sternotomy is exclusively applied in the majority of cardiac operations. A right thoracotomy has been used in patients who underwent aortic valve replacement after an esophageal operation and reoperation for coronary revascularization [3–6]. However, reports describing the use of the right thoracic approach for ascending aortic operations are few [1]. Recent reports revealed that minimal access aortic surgery was feasible however demanding more technique [2].
In patients whose anterosternal space is occupied by a colon interposition, replacement of the ascending aorta has to be performed through a right thoracotomy approach because a median approach is not only dangerous but technically unfeasible. Aortic replacement under right thoracotomy approach is rarely mentioned; therefore, careful consideration was employed both before and during the operation. Preoperative 3D-CT confirmed that a better surgical view could provided through this approach and aortic clamping around the aortic arch would be difficult because of the limitation of the surgical field, therefore, deep hypothermic circulatory arrest was preferred for cerebral protection. Selective cannulation to right coronary ostium was difficult in this case, however would be easier using some retractor [2].
We believe that a right thoracotomy approach is applicable for replacement of the ascending aorta in the patient whose parasternal space is occupied by a colon interposition after an esophageal operation. Therefore, right thoracotomy also should be reserved as an alternative method for similar cardiovascular operations in certain limited situations.
|
References
|
|---|
-
Pretre R., Turina M.I. Resection of ascending aorta aneurysm in redo surgery through an anterior thoracotomy. J Card Surg 1999;14:363-365.[Medline]
-
Svensson L.G., Nadolny E.M., Kimmel W.A. Minimal access aortic surgery including re-operations. Eur J Cardiothorac Surg 2001;19:30-33.[Abstract/Free Full Text]
-
Uppal R., Wolfe W.G., Lowe J.E., Smith P.K. Right thoracotomy for reoperative right coronary artery bypass procedure. Ann Thorac Surg 1994;57:123-125.[Abstract]
-
Gillinov A.M., Casselman F.P., Cosgrove D.M. Aortic valve replacement after substernal colon interposition. Ann Thorac Surg 1999;67:838-839.[Abstract/Free Full Text]
-
Matsuda H., Okada M., Yamashita C., Sugimoto T., Watanabe Y. Aortic valve replacement after retrosternal gastric tube reconstruction for esophageal cancer (in Japanese). Jpn J Thorac Cardiovasc Surg 1999;47:234-236.[Medline]
-
Kabuto T., Yasuda T., Furukawa H., Higashiyama M., Takami K., Yokouchi H., Kodama K., Takami H., Kobayashi T. Combined resection of the aorta for an esophageal carcinoma invading the aorta through a right transthoracic approach (in Japanese). Jpn J Thorac Cardiovasc Surg 1999;47:611-616.[Medline]
Top
Abstract
1. Introduction
