Asian Cardiovasc Thorac Ann 2004;12:374-375
© 2004 Asia Publishing EXchange Ltd
The Prevention of Nerve Injury in Aortic Arch Aneurysmal Surgery
Yukio Kuniyoshi, MD,
Kageharu Koja, MD,
Kazufumi Miyagi, MD,
Tooru Uezu, MD,
Satoshi Yamashiro, MD,
Katuya Arakaki, MD
Second Department of Surgery, Faculty of Medicine, University of the Ryukyus, Okinawa, Japan
For reprint information contact: Yukio Kuniyoshi, MD Tel: 81 98 895 1168 Fax: 81 98 895 1422 Email: kuni9244{at}med.u-ryukyu.ac.jp Second Department of Surgery, Faculty of Medicine, University of Ryukyus, 207 Uehara Nishihara-cho, Okinawa 903-0215, Japan.
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ABSTRACT
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In a case of aortic arch aneurysm associated with adhesion to the surrounding structures, we devised an operative technique to avoid nerve injury during the surgical procedure. By preserving the adventitial layer of the aortic arch aneurysm to which the phrenic and recurrent nerves were attached, injury to the nerves was avoided, and the aneurysmectomy was completed with the distal anastomosis being performed intraluminally.
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INTRODUCTION
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There are few reports that deal with prevention of injury to the phrenic and recurrent nerves during aortic arch surgery. This may be because such nerve injuries have not occurred frequently, and although they are associated with some morbidity, are not fatal. However, this complication can prove quite problematic for patients who have preoperative respiratory dysfunction1,2 and may affect prognosis. Accordingly, we present a new technique for avoiding nerve injury during aortic arch surgery.
The patient was a 72-year-old man with an aortic arch aneurysm. Preoperative computed tomography showed presence of a saccular shaped arch aneurysm with a maximal diameter of 58 mm (Figure 1
). The patient displayed evidence preoperatively of respiratory dysfunction. Arterial blood gas analysis revealed presence of hypoxemia under room air conditions (pH: 7.444, PaO2: 61.3 mm Hg, PCO2: 41.0 mm Hg, O2 saturation 93.0%). Aneurysmectomy and graft replacement of the aortic arch were carried out with adjuncts of hypothermic extracorporeal circulation with circulatory arrest and selective cerebral perfusion. In order to gain access to the distal anastomosis site, we attempted to free the aneurysm from the surrounding lung parenchyma, which was tightly adherent to the aneurysm. However, this attempt was abandoned due to concerns about nerve damage, and a different approach was adopted.
At this point the ascending aorta was transected, and the adventitia carefully dissected away from the media and intima of the aneurysm, which were excised and discarded. Proceeding intraluminally, the adventitia of the distal anastomotic site was incised circumferentially and the distal anastomotic ostium was prepared (Figure 2). The distal anastomosis of the graft to the thoracic aorta was carried out intraluminally without difficulty, since the dissected adventitia was soft and pliable and caused no restriction to the anastomotic procedure. After completion of the distal anastomosis, antegrade perfusion was restored and the arch branches were reconstructed from a distal to a proximal direction. The patient was extubated on the fourth postoperative day, and experienced no hoarseness or other evidence of phrenic nerve injury. The patient recovered uneventfully and was discharged without any postoperative complications (Figure 3).
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Figure 2. (Left) The nerves running across the arch aneurysm are buried under the aneurysmal wall. The intima and media of the aneurysmal wall are removed (indicated by arrow) and the adventitia is preserved without touching the nerves. (Right) At the distal anastomotic site, the adventitia is incised circumferentially for distal anastomosis. The procedures are performed intra-aneurysmally.
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Figure 3. Postoperative angiogram of the left anterior oblique view. The left subclavian artery was used for the arterial infusion line by anastomosis with an 8 mm graft, and reconstructed by anastomosis with one of the branches of the arch graft (black arrows).
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DISCUSSION
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There are few reports concerning the prevention of nerve injury during arch aneurysm surgery. There have been reports of an operative procedure where the graft is pulled through the arch aneurysm in cases of aneurysm rupture or rupture into the lung parenchyma,3 which may help to preserve nerves that are adherent to the aneurysm. However ours is the first report in which the entire procedure was performed intraluminally. In cases where the aortic aneurysm is localized in the aortic arch and has adhesions that are too severe to be freed from the surrounding structures in order to approach the distal anastomotic site, nerve injury can be avoided by our operative procedure. In particular, this method can be useful in cases where the patient is affected with respiratory dysfunction.Another advantage of this operative procedure is that in manipulating the aneurysmal wall to separate it from media and intima, the wall becomes soft and pliable, which facilitates the identification of the nerves that run parallel to the arch branches.
Although we have yet to carry out this procedure in another case, we have the impression that it is reproducible. Our experience with aortic arch aneurysms suggest that in most cases the adventitia can easily be dissected away from the inner vascular layers, and that it would normally be expected to be quite soft and pliable. Furthermore, in the case described above the operative time was not excessive, and the entire procedure was completed in 7 hours.
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REFERENCES
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1999;117:99–105.[Abstract/Free Full Text]
- Kazui T, Washiyama N, Muhammad BA, Terada H, Yamashita K, Takinami M. Improved results of atherosclerotic arch aneurysm operations with a refined technique. J Thorac Cardiovasc Surg
2001;121:491–9.[Abstract/Free Full Text]
- Beaver TM, Martin TD. Single-stage transmediastinal replacement of the ascending, arch, and descending thoracic aorta. Ann Thorac Surg
2001;72:1232–8.[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
