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Eur J Cardiothorac Surg 2006;30:815-816
© 2006 Elsevier Science NL
Letters to the Editor |
Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Center Istanbul, Turkey
Received 28 June 2006; accepted 2 August 2006.
* Corresponding author. Address: Merdivenkoy Mah., Sairarsi Cad., Emincinarpasa Sok. No: 6/24, Goztepe/Kadikoy, Istanbul, Turkey. Tel.: +90 216 360 0272; fax: +90 216 360 0272. (Email: drmates{at}yahoo.com).
Key Words: Axillary cannulation • Aortic surgery • Acute aortic dissection
We read with interest the article entitled ‘Axillary cerebral perfusion for arch surgery in acute type A dissection under moderate hypothermia’ by Panos et al. [1]. Open distal aortic repair is still one of the best choices in acute type A aortic dissections [2]. It is still controversial among the vascular surgeons with regard to priority of the side of aortic repair (proximal or distal). We also prefer open distal anastomosis in acute type A dissections in our institute.
In spite of the availability of different suture techniques, there is no report that shows which one is the best. In fact, of the different dissected aortic tissue, to obtain the right kind for the study is almost impossible. In our clinic, we are using interrupted pledgeted suture technique in acute type A dissection procedures and the results are accurate in terms of bleeding [3].
In the present study, the authors performed open aortic arch repair with continuous antegrade brain perfusion by means of direct cannulation of the right axillary artery, under moderate hypothermia, in 25 consecutive patients with acute type A aortic dissection [1]. In one of the patients, post-operative 4th day left arm paralysis developed and was cured with stented graft. Like Coselli and co-workers [4] we believe that instead of axillary artery direct cannulation with a 4% (1/25) additional risk rate, achieving antegrade cerebral perfusion via axillary artery grafting with a suitable graft is more appropriate in patients with acute aortic dissection. In our clinic, in both acute and chronic aortic dissection cases, axillary cannulation is performed via suitable graft, which is always 8 mm, and has no morbidity related to axillary cannulation. The other subject that we wonder about is the cause of mortality in one case. It could be more favorable if the authors pointed out this issue.
Antegrade cerebral perfusion is being performed even when the point of deep or moderate hypothermic perfusion is controversial [4]. We believe that the safety and quality of distal anastomosis is the most important factor for mortality and morbidity, so we think that the quality of distal anastomosis is more considerable than wasting time. We use deep hypothermia, but moderate hypothermia can also be used with more experience.
An additional comment is that in case of dissection that advanced to left main and right coronary arteries with high-grade aortic insufficiency, bicuspid aorta and degenerative aortic valve disease, we prefer inserting composite graft first and then fixating the upper side of left main coronary artery with pledgeted sutures and suturing just lateral and upper side without down side because of intensive fragility during Bentall operation. Punching the composite graft near the valve and in a slightly horizontal position is enough to achieve this procedure.
In our opinion, the surgeon should avoid Bentall procedure as far as possible because resuspension of aortic valve is sufficient in 90% of the cases in acute terms; because of this, tissues become very fragile.
References
This article has been cited by other articles:
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  A. Panos, N. Murith, M. Bednarkiewicz, and G. Khatchatourov Reply to Ates and Gullu Eur. J. Cardiothorac. Surg., November 1, 2006; 30(5): 816 - 816. [Full Text] [PDF]
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