Asian Cardiovasc Thorac Ann 2007;15:72-73
© 2007 Asia Publishing EXchange Ltd
The Sock Method for a Distal Ascending Aneurysm
Katsuhiko Matsuyama, MD,
Masaharu Yoshikawa, MD1,
Yuji Narita, MD1,
Yuich Ueda, MD1
Department of Cardiovascular Surgery Chubu Rosai Hospital
1 Department of Cardio-Thoracic Surgery Nagoya University Graduate School of Medicine Nagoya, Japan
For reprint information contact: Katsuhiko Matsuyama, MD, Tel: 81 52 652 5511, Fax: 81 52 653 3533, Email: k-matsuy{at}f3.dion.ne.jp, Department of Cardiovascular Surgery, Chubu Rosai Hospital, 1-10-6 Komei, Minato-ku, Nagoya 455-8530, Japan.
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ABSTRACT
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Although conservative operations such as reduction aortoplasty or wrapping for an ascending aortic aneurysm remain controversial procedures, the wrapping method has recently shown good long-term results. We report the sock method as an alternative wrapping procedure for an ascending aneurysm extending to the base of the innominate artery. This simple method can easily be performed in selected patients.
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INTRODUCTION
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Ascending aorta aneurysms are common in patients with aortic disease, and the operation most commonly used is a combination of an aortic valve replacement or root replacement. If the ascending aortic aneurysms extend to the proximal innominate artery, then an open distal anastomosis under circulatory arrest may be considered. However, this radical procedure increases the operative risk, including neurological complications and bleeding, and also requires cooling, rewarming, and a prolonged bypass time. As an alternative procedure, a conservative operation such as an aortoplasty or wrapping has been reported.1–3 Although the conservative procedures were controversial, the long-term results of reduction aortoplasty and wrapping procedures are satisfactory, compared to the risk of a radical operation.1–4 We report the sock method as an alternative wrapping procedure for a dilated distal ascending aorta.
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TECHNIQUE
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The operative plan was scheduled in a patient who had aortic regurgitation complicated with an annular dilatation and entire ascending aortic dilatation; the diameter of the distal ascending aorta was 4.5 cm. An aortic cannula for cardiopulmonary bypass was placed in the distal ascending aorta. The aorta was then crossclamped at the base of the aortic cannula. Aortic root replacement was first performed by a modified Bentall operation with a 26 mm composite woven Dacron graft. Then, another 26 mm Dacron graft was trimmed to a length of 8.0 cm, forcing each edge to abduct to a degree of 1.0 cm. The graft was placed on the composite graft before the start of the distal anastomosis (Figure 1
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Figure 1. After a modified Bentall, another 26 mm Dacron graft was trimmed to a length of 8.0 cm, forcing each edge to abduct to a degree of 1.0 cm. The graft was placed on the composite graft before the start of the distal anastomosis.
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After weaning from cardiopulmonary bypass, the aortic cannula was first removed. Then, the Dacron graft with the composite graft was socked onto the entire distal ascending aorta for wrapping while the blood pressure was temporarily lowered by drainage from the venous cannula. The Dacron graft was well fitted just proximal to the innominate artery (Figure 2). Finally, the Dacron graft was secured against dislocation by distal anchoring stitches.
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Figure 2. The Dacron graft with the composite graft was socked onto the entire distal ascending aorta for wrapping.
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DISCUSSION
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It is important to dissect around the distal ascending aorta to the proximal aortic arch, and care should be taken not to injure the reconstructed right coronary ostium by another Dacron graft before socking. The advantages of this sock method are that it is very simple and fast, and that the distal dilated aorta, including the distal anastomotic site plus the cannulation site, can be more smoothly and tightly wrapped than by the original wrapping.5 The inner curve design as determined by computed tomography was very smooth and clear, without any folding. This method also has the advantage of reducing the risks of bleeding at the anastomotic site and of graft dislocation due to poor fitting to the aorta.
In a case with discrepancy of the size between the aortic end and the graft, this method is not applicable, and dilatation extending beyond the origin of the innominate artery is also not indicated. The indications for this method are limited to patients with a distal ascending aortic diameter of < 5.0 cm. In Marfan patients, this method may be useful if applicable.
Although the long-term results of this method are unknown, we believe that this simple method can be performed safely in selected patients.
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REFERENCES
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- Robicsek F, Cook JW, Reames MK Sr, Skipper ER. Size reduction ascending aortoplasty: is it dead or alive? J Thorac Cardiovasc Surg 2004;128:562–70.[Abstract/Free Full Text]
- Ogus NT, Cicek S, Isik O. Selective management of high risk patients with an ascending aortic dilatation during aortic valve replacement. J Cardiovasc Surg (Torino) 2002;43:609–15.[Medline]
- Robicsek F, Thubrikar MJ. Conservative operation in the management of annular dilatation and ascending aortic aneurysm. Ann Thorac Surg 1994;57:1672–4.[Abstract]
- Bauer M, Pasic M, Schaffarzyk R, Siniawski H, Knollmann F, Meyer R, et al. Reduction aortoplasty for dilatation of the ascending aorta in patients with bicuspid aortic valve. Ann Thorac Surg 2002;73:720–4.[Abstract/Free Full Text]
- Smith RB 3rd, Constantino MJ, Perdue GD Jr. Is there a place for external grafting of arterial aneurysms in selected patients? J Cardiovasc Surg (Torino) 1979;20:13–20.[Medline]
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ABSTRACT
INTRODUCTION
