Eur J Cardiothorac Surg 2006;29:255-257
© 2006 Elsevier Science NL
Total arch replacement using a stepwise distal anastomosis for arch aneurysms with distal extension
Hitoshi Ogino
a
,
*
,
Motomi Ando
b
,
Hiroaki Sasaki
a
,
Kenji Minatoya
a
a Department of Cardiovascular Surgery, National Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka 565-8565, Japan
b Department of Thoracic Surgery, Fujita Health University, Mizukake-cho, Toyoake, Aichi 470-1192, Japan
Received 2 August 2005;
received in revised form 17 October 2005;
accepted 19 October 2005.
* Corresponding author. Tel. +81 6 6833 5012; fax: +81 6 6872 7486. (Email: hogino{at}hsp.ncvc.go.jp).
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Abstract
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A total of 120 patients having arch to distal arch aneurysm with downstream extension underwent total arch replacement, with individual arch-vessel reconstruction through median sternotomy using a novel ‘stepwise’ distal aortic anastomosis. Cardiopulmonary bypass was established by cannulating the right axillary artery and the ascending aorta or femoral artery. Hypothermia was at 22–28 °C. Through the aneurysm, the descending aorta was divided. Distal anastomosis using the stepwise technique was performed; a tube graft of length 7–12 cm was inserted into the descending aorta and anastomosed by running suture. The distal end of the inserted graft was extracted, and a further four-branched arch graft was joined to it. Selective cerebral perfusion was used for cerebral safety during arch repair. There were three hospital deaths (2.5%). Two patients (1.7%) developed permanent neurological dysfunction and three patients (2.5%) suffered transient cerebral deficits. Three patients (2.5%) required reentry for postoperative bleeding although in none of them bleeding was from the distal anastomosis site with the stepwise technique. Stepwise anastomosis is a useful and secure alternative for distal anastomosis in total arch replacement for arch to distal arch aneurysms with distal extension.
Key Words: Aortic arch • Aneurysm • Aortic dissection • Aortic surgery
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1. Introduction
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For arch to distal arch aneurysms, it is not agreed whether a median or lateral approach is better, particularly for aneurysms with distal extension [1–7]. The median approach aims to provide cerebral and cardiac safety [1–4]. However, the distal anastomosis is often difficult and bleeding from it is a serious problem [6,7]. We have therefore used a novel stepwise technique providing a technically easy and secure anastomosis.
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2. Patients and methods
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Between 1999 and 2003, 120 patients (74 years old) having an arch to distal arch aneurysm underwent total arch replacement. Of these, 112 patients had non-dissecting and two had dissecting aneurysms. The other six had a combined pathology. Ten patients required emergency surgery.
The aneurysm was approached through median sternotomy (Fig. 1A). After full heparinization, a 10–16 Fr straight thin-wall cannula was inserted into the right axillary artery (RAxA) on the right armpit [8]. Cardiopulmonary bypass (CPB) was established by cannulation involving also the femoral artery or the ascending aorta. The patients were cooled to 22–28 °C. Following hypothermic circulatory arrest, selective cerebral perfusion (SCP) was begun through the RAxA perfusion by clamping the brachiocephalic artery (BCA). The arch was opened and a 12 Fr SCP balloon cannula was inserted into the left common carotid artery (LCCA) (Fig. 1B). In recent series with moderate hypothermia at 25–28 °C, the left subclavian artery (LSCA) was also perfused. With SCP, the descending aorta was divided through the aneurysm. Distal aortic anastomosis was done using a stepwise technique. First, an invaginated tube graft of length 7–12 cm (a piece of the quadrifurcated arch graft) was inserted into the descending aorta (Fig. 1C). The position of the proximal end of the invaginated graft was adjusted to match the level of the divided end of the descending aorta. The anastomosis was then easy to perform, with a good surgical view, using an over and over running suture of 3-0 or 4-0 polypropylene, with reinforcement by Teflon felt strip (Fig. 2A). The distal end of the inserted graft was extracted proximally. For arch reconstruction, a further four-branched arch graft was attached to this stepwise graft using a running 3-0 polypropylene suture (Fig. 2B). Antegrade aortic perfusion was initiated. The LSCA was reconstructed with a branch graft. Rewarming was then initiated. The proximal anastomosis was done above the sinotubular junction. Finally, the LCCA and the BCA were reconstructed (Fig. 2C). The RAxA perfusion was discontinued. In recent cases, our stepwise technique was refined to reinforce the anastomosis and prevent bleeding from the anastomosis (Fig. 1D). In making the stepwise graft, 2–3 cm of the proximal end was left without invagination so as to reinforce the anastomosis from the inside by a ‘sandwich’ technique with the Teflon felt strip. We call this ‘mini-elephant trunk technique’. Coronary artery bypasses grafting in 23, aortic valve replacement in one, and mitral valve plasty in one were also performed.
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Fig. 1. Total arch replacement using selective cerebral perfusion and stepwise distal anastomosis. (A) Distal arch aneurysm: black arrows show cannulation sites on the right axillary artery and the ascending aorta for cardiopulmonary bypass. (B) Brain protection with antegrade selective cerebral perfusion (SCP): large (right axillary artery perfusion) and small (left common carotid and left subclavian artery perfusion) arrows show SCP. The descending aorta was divided from the inside through the aneurysm. (C) An invaginated tube graft was inserted into the descending aorta. (D) Recent refined technique (mini-elephant trunk technique): 2–3 cm of the proximal end was left without invagination so as to reinforce the anastomosis from the inside by a ‘sandwich’ technique with the outside Teflon felt strip. The distal end was also tucked inside to shorten the length of the graft, in order to prevent dislodge of the mural atheroma.
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Fig. 2. Stepwise distal anastomosis. (A) Stepwise distal anastomosis with the reinforcement of outside Teflon felt strip using a running suture. (B) The distal end of the inserted graft was extracted and a quadrifurcated arch graft was connected to this end. (C) Total arch replacement using a stepwise anastomosis: the numbers show the turn of anastomosis.
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3. Results
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The median duration of lower body circulatory arrest, SCP, CPB, and surgery were 68, 147, 209, and 415 min, respectively. The median transfusion volume was 2400 ml. There were three hospital deaths (2.5%) from perioperative myocardial infarction, low cardiac output with bowel necrosis, and mediastinitis. Two patients (1.7%) developed permanent neurological dysfunction (small stroke), and three patients (2.5%) suffered from transient cerebral deficits. Three patients (2.5%) required reentry for bleeding. In none of them, bleeding from the distal anastomosis was found. Other complications occurred: low cardiac output in 5.0%, respiratory failure in 10.0%, renal failure in 3.3%, hepatic failure in 0.8%, bowel necrosis in 1.7%, and sepsis in 0.8%.
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4. Discussion
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The most common approach for arch to distal arch aneurysms is currently through median sternotomy [1–4]. This approach aims to provide cerebral and cardiac safety. However, the distal anastomosis tends to be difficult because of poor, distant, and limited view [6,7]. In our technique, the arch aneurysm is not incised to prevent injury to the nerves and lung. Through the aneurysm, the descending aorta is divided and the distal anastomosis takes place. Subsequently, the surgical view is limited. Furthermore, bleeding from this anastomosis is a major concern. We have therefore evolved a novel stepwise technique, which made the distal anastomosis around the hilum feasible in our experience.
The end of the descending aorta is often fragile with much atherosclerosis. Even with the stepwise technique, we experienced bleeding from the anastomosis in seven patients. The stepwise technique was therefore refined by the "mini-elephant trunk". With this refinement, we have not experienced any major bleeding from the distal anastomosis.
The stepwise technique has some drawbacks. Graft insertion carries a risk of dislodging mural atheroma. We experienced one case of bowel necrosis. To prevent this problem, in the refined technique, the distal end was tucked inside to shorten the graft length. Graft insertion must be done carefully into the atheromatous descending aorta. Direct anastomosis of a short-length graft without graft insertion is a good alternative. Another disadvantage is the need for a graft–graft anastomosis, which is fortunately easy with a good view taking 5–10 min.
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Footnotes
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This paper was presented in the Aortic Surgery Symposium VI in New York in 2004.
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References
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Abstract
1. Introduction
