Asian Cardiovasc Thorac Ann 2008;16:416-418
© 2008 Asia Publishing EXchange Ltd
Simple and Reliable Distal Anastomosis for Total Aortic Arch Replacement
Akihiko Ohkado, MD,
Akiko Tanaka, MD,
Akitoshi Yamada, MD,
Kyozo Inoue, MD,
Noboru Wakita, MD
Department of Cardiovascular Surgery, Kobe Rosai Hospital, Kobe, Japan
For reprint information contact: Akihiko Ohkado, MD, Tel: 078 855 9151, Fax: 078 251 5033, Email: aki-ohkado{at}ohkado-heart-clinic.com, OHKADO Heart Clinic, Art Center of Kobe Medical Mall 4F, 7-1-13, Kumochibashi-dori, Chuo-ku, Kobe, Hyogo 651-0055, Japan.
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ABSTRACT
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In total aortic arch replacement, distal aortic anastomosis is often remarkably difficult because of the deep operative field. Once bleeding from the anastomotic area occurs, it is intractable not only because of technical problems but also decreased coagulability due to deep hypothermia and the fragility of the aortic wall. We describe a simple but reliable strategy for distal anastomosis, which is unique with regard to the approach to the anastomotic area and the anastomotic method.
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INTRODUCTION
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In total aortic arch replacement, distal anastomosis at the descending aorta is often remarkably difficult, and bleeding from the anastomotic area is intractable because of the deep surgical field. There have been several reports of unique techniques for distal anastomosis in aortic arch replacement.1–5 We describe a simple but effective strategy to achieve reliable distal anastomosis with no difficulty.
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TECHNIQUE
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Cardiopulmonary bypass is established by arterial and right atrial cannulation. Profound deep hypothermia and selective cerebral perfusion are employed for brain protection. During systemic cooling, the ascending aorta and the arch vessels are taped, and the space between the aorta and the pulmonary artery is widely dissected. In the case of aortic dissection, reinforcement of the proximal aorta is completed while clamping the ascending aorta. After induction of hypothermic circulatory arrest at a tympanic temperature < 20°C, a longitudinal aortotomy is made on the anterior aspect of the ascending aorta. Selective cerebral perfusion is started as quickly as possible. The aortotomy is extended distally but never beyond the arterial ligament to protect the recurrent and phrenic nerves, and transversely, and the posterior aspect of the aorta is incised longitudinally until it reaches the distal anastomotic area of the descending aorta. The left mediastinal pleura is widely opened so that the distal anastomotic area can be approached and palpated directly from the lateral side through the left thoracic cavity. This maneuver makes distal anastomosis quite easy and secure (Figure 1
). For quick and accurate transection of the descending aorta in the deep surgical field, DeBakey valve scissors (Pilling Weck, Markham, Canada) are very useful as the blades are acutely curved. The mediastinal pleura covering the lateral wall of the anastomotic area is left to be used as reinforcement material for anastomosis. Small arterial branches around the anastomotic area are ligated and severed at this point. A double-layer graft, approximately 3 cm long, is introduced into the transected aorta with its cuff side accurately adjusted to the suture line. A Teflon felt strip is positioned outside to reinforce the anastomosis. Several intermittent sutures are placed on its circumference to prevent dislodgment of the graft and felt strip. The felt strip, mediastinal pleura, aorta, and both layers of the graft are tightly sewn together using an over-and-over continuous suture of 4/0 polypropylene (Figure 2A). The inner layer of the graft is pulled out, while the outer layer works as an "elephant trunk" (Figure 2B). After the former is anastomosed to the 4-branched graft, graft perfusion is started. During systemic rewarming, reconstruction of the arch vessels and proximal anastomosis of the graft to the ascending aorta are completed.
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Figure 1. A longitudinal aortotomy continues anteriorly and distally, but never beyond the arterial ligament; it is extended transversely and posteriorly towards the distal anastomotic area; the left mediastinal pleura is widely opened, leaving the one around the anastomotic area.
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Figure 2. (A) A double-layer graft is introduced into the transected aorta; A Teflon felt strip, the pleura, aorta, and graft are tightly sewn together using an over-and-over continuous suture of 4/0 polypropylene; (B) The inner layer of the graft is pulled out, while the outer layer works as an "elephant trunk".
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DISCUSSION
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Between January 2002 and September 2006, we applied our technique in 39 patients (aged 71 ± 9 years, 22 male and 17 female). Of 7 operative deaths (< 30 days), 4 were due to rupture of the aneurysm followed by multiorgan failure, 1 was caused by pulmonary bleeding, and 1 was due to critical perioperative myocardial infarction; only 1 with acute dissection died from uncontrollable bleeding. Although the bleeding site was unclear, bleeding from the distal anastomotic area had not been observed just before sternal closure.
Total aortic arch replacement is a well-established procedure for aortic aneurysms involving the transverse aortic arch. However, in addition to brain protection, hemostasis is crucial to satisfactory operative results. Bleeding from the distal anastomotic area is mainly caused by technical problems, but decreased coagulability due to deep hypothermia and the fragility of the aortic wall in cases of aortic dissection are contributory factors. Bleeding is often intractable after discontinuation of cardiopulmonary bypass because of the extremely deep surgical field. Therefore, an absolutely reliable anastomosis that is resistant to bleeding is required. In our method, wide opening of the left mediastinal pleura and use of scissors with acutely curved blades facilitates exposure and evaluation of the distal anastomotic area, leading to simple but reliable anastomosis. Moreover, the mediastinal pleura covering the lateral side of the anastomotic area can be useful as reinforcement material for tight anastomosis.
Our anastomotic method is similar to that reported by Rignano and colleagues.6 An additional hemostatic stitch is easy as the suture line is completely external. Therefore, bleeding from the anastomosis after starting graft perfusion is rare and easily controlled if necessary. For protection of the recurrent and phrenic nerves, we applied limited incision of the anterior aortic wall. Although it appears that the retained aortic wall may disturb surgical manipulation, the above-mentioned approach and complete transection of the descending aorta overcome this drawback. It should be noted that this strategy may not be applied when there are dense adhesions between the pleura and the left lung, and that postoperative drainage of the left thoracic cavity is necessary.
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REFERENCES
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- 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]
- Mori Y, Hirose H, Takagi H, Umeda Y, Fukumoto Y, Shimabukuro K, et al. Aortic arch repair for Stanford type A aortic dissection with distal anastomosis to the proximal level of the distal aortic arch. J Thorac Cardiovasc Surg 2003;126:415–9.[Abstract/Free Full Text]
- Sakamoto T, Yoshida T, Sugano T, Kudoh A, Susuki A. Simplified technique for hemi-arch replacement during open distal anastomosis: the "calla" method. Ann Thorac Surg 1996;61:1021–3.[Abstract/Free Full Text]
- Borst HG, Walterbusch G, Schaps D. Extensive aortic replacement using "elephant trunk" prosthesis. J Thorac Cardiovasc Surg 1983;31:37–40.
- Alexiou C, Sosnowski AW. Tube-graft inversion for the construction of an "open" distal anastomosis during ascending aortic replacement: a new technique. Ann Thorac Surg 2007;83:326–8.[Abstract/Free Full Text]
- Rignano A, Keller GC, Carmo M, Anguissola GB, Settembrini PG. A new approach for proximal anastomosis in type "A" acute aortic dissection: prosthesis eversion. Ann Thorac Surg 2003;76:949–51.[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
