Asian Cardiovasc Thorac Ann 2007;15:261-263
© 2007 Asia Publishing EXchange Ltd
Modified Sandwich Technique for Acute Aortic Dissection
Toshihiro Ohata, MD,
Yuji Miyamoto, MD,
Masataka Mitsuno, MD,
Mitsuhiro Yamamura, MD,
Hiroe Tanaka, MD,
Masaaki Ryomoto, MD
Department of Cardiovascular Surgery, Hyogo College of Medicine, Hyogo, Japan
For reprint information contact: Yuji Miyamoto, MD Tel: 81 798 456 852 Fax: 81 798 456 853 Email: y-miyamo{at}hyo-med.ac.jp, Department of Cardiovascular Surgery, Hyogo College of Medicine, 1-1 Mukogawa, Nishinomiya, Hyogo 663-8501, Japan.
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ABSTRACT
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We describe a new method for aortic anastomosis in the repair of acute type A aortic dissection. The anastomosis site is prepared with the adventitial inversion technique, which converts a dissected aorta into a conduit lined with tough adventitia. The end is reinforced with felt strip outside and anastomosed with interrupted everting mattress and running sutures, resulting in complete hemostasis. This modified sandwich technique will likely be useful for the surgical treatment of acute aortic dissection.
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INTRODUCTION
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Surgical outcomes in patients with acute aortic dissection have been improved significantly in recent years due to prompt diagnosis and improved perioperative care and operative technique.1 However, postoperative morbidity and mortality are often caused by irreversible organ damage and anastomosis complications such as bleeding and dehiscence.2 Folten and colleagues described an adventitial inversion technique to reinforce the remainder of the aorta at the anastomosis site.3 The adventitia and its adjacent elastic laminae remain intact after the trimming and are tough, and an everting suture might strengthen the anastomosis. We hypothesized that unfolding this layer and using it as a graft turn-up would facilitate the anastomosis, and that using a double suturing technique would reduce the risk of bleeding or dehiscence. Intraoperative bleeding could be reduced by using this new operative technique for acute aortic dissections.
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METHOD
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Our method for repairing acute type A aortic dissection involves inverting a cuff of aortic adventitia to construct the distal and proximal anastomosis and using a combination of everting mattress and running sutures to re-attach the graft.
Cardiopulmonary bypass is established with venous drainage from the right atrium and return into the axillary or femoral artery. The systemic temperature is lowered to 25°C. If no thrombus is present in the open false lumen, the aorta is cross clamped, and cold blood cardioplegic solution is infused retrogradely. The aorta is opened, and the intima of the proximal site is transected circumferentially about 1.0 cm above the Sino-tubular junction. Plication of the aortic valve is performed if needed. The adventitia is turned inside to cover the intima and secured with 4-0 prolene running sutures to an outer felt strip placed to reinforce the proximal cuff (Figure 1
). When the bladder temperature reaches 25°C, perfusion is stopped, and the ascending aorta is opened. The existence and the location of the intimal tear are confirmed, and the area of the dissection is examined for thrombus. After resection of any thrombus, a 14 Fr cannula is inserted into the brachiocephalic artery and a 12 Fr cannula into the left common carotid artery, and selective cerebral perfusion is started. A Fogarty occlusion balloon is inserted into the left subclavian artery to control bleeding.
The distal cuff is prepared with the adventitial inversion as on the proximal side. A collagen coated graft (Hemashield, Meadox Medical, Oakland, NJ, USA) is anastomosed with four everting mattress sutures of 2-0 polybutylate-coated braided polyester (Ethibond, Ethicon Inc., Somerville, NJ, USA) (Figure 2), and 3-0 polypropylene (Prolene, Ethicon Inc., Somerville, NJ, USA) running sutures are placed at the outermost side (Figures 3, 4). After completion of the distal anastomosis, reperfusion of the body is started. During systemic rewarming, another Hemashield graft is anastomosed with four everting mattress and running sutures for the proximal anastomosis as on the distal side. The two grafts are trimmed and anastomosed with 4-0 prolene running sutures.
For cases complicated by an open false channel with thrombosis or by dissection of carotid branches, the distal adventitial and graft turn-up procedure is performed first under selective cerebral perfusion. Proximal management and graft-graft anastomosis are carried out during systemic rewarming.
Between January and September 2005, we used this modified sandwich technique in 10 cases of acute aortic dissection. The mean duration of cardiopulmonary bypass was 166 min (range, 145–185 min), the mean duration of cerebral perfusion was 43 min (range, 32–54 min), and the mean operative bleeding was 397 mL (range, 220–790 mL). Using this new suturing technique, we can achieve complete hemostasis in type A acute aortic dissection.
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DISCUSSION
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Surgical repair of acute aortic dissection can be very complex because of the extreme friability of the aortic tissue, and hospital mortality is still high (10–20%),2 largely owing to anastomosis complications such as bleeding and dehiscence. Methods currently employed to minimize suture line complications make use of Teflon felt strips for reinforcement combined with biologic glue (gelatin-resorcin-formalin). The procedure of applying this glue is tedious, and it can damage the surrounding tissue. The use of biologic glues to re-approximate layers of the dissected aortic root is reported to be associated with increased risk of aortic wall necrosis.4
Various techniques of aortic anastomosis have been reported to reduce anastomosis complications in the repair of aortic dissection,3,5 such as the so-called sandwich technique.6 Our method has three main advantages: the stiffness of the cuff, the broadness of surface area between the graft and native aortic wall, and the safety of cerebral perfusion during the distal anastomosis. The proximal and distal stumps are reinforced by the adventitial inversion and the outer felt strip. The surface area between the graft and the native aortic wall is significantly increased by the graft turn-up procedure, and complete hemostasis can be achieved by the graft turn-up and the additional continuous sutures.
In our patients, we applied this technique only in replacement of the ascending aorta. However we hypothesize that partial arch replacement or total arch replacement can be performed with this technique if the intimal tear continues to the aortic arch. Although complicated, these procedures can be performed safely under selective cerebral perfusion with moderate hypothermia. As a result, intraoperative and postoperative bleeding was reduced. The adventitial inversion and graft turn-up method, or modified sandwich technique, will likely be useful for the surgical treatment of acute aortic dissection.
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REFERENCES
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- Dinis Da Gama A. The surgical management of aortic dissection: from uniformity to diversity, a continuous challenge. J Cardiovasc Surg (Torino) 1991;32:141–53.[Medline]
- Svensson LG, Crawford ES, Hess KR, Coselli JS, SafiHJ. Dissection of the aorta and dissecting aortic aneurysms. Improving early and long-term surgical results. Circulation 1990;82(5 Suppl):IV24–38.[Medline]
- Folten HS, Ravichandran PS, Furnary AP, Gately HL, Starr A. Adventitial inversion technique in repair of aortic dissection. Ann Thorac Surg 1995;59:771–2.[Abstract/Free Full Text]
- Fukunaga S, Karck M, Harringer W, Cremer J, Rhein C, Haverich A. The use of gelatin-resorcin-formalin glue in acute aortic dissection type A. Eur J Cardiothorac Surg 1999;15:564–70.[Abstract/Free Full Text]
- Oda K, Akimoto H, Hata M, Akasaka J, Yamaya K, Iguchi A, et al. Use of cuffed anastomosis in total aortic arch replacement. Ann Thorac Surg 2003;76:952–3.[Abstract/Free Full Text]
- Stone C, Borst H. Dissecting aortic aneurysm, in Cohn LH and Edmunds LH Jr: Cardiac surgery in the adult. Second Edition. New York: McGraw-Hill, 2003:1109.
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ABSTRACT
INTRODUCTION
