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Pericardial Reinforcement for Hemostasis in Aortic Aneurysm Surgery

Department of Cardiovascular Surgery 1 Department of Cardiology Sanjay Gandhi Post-Graduate Institute of Medical Science Lucknow, India

For reprint information contact: Ashok K Srivastava, MS, MCh Tel: 91 522 44 0963 Fax: 91 522 44 0017/ 0973 email: ashok{at}sgpgi.ac.in Department of Cardiovascular Surgery, Sanjay Gandhi Post-Graduate Institute of Medical Science, Raebareli Road, Lucknow 226014, India.

	Abstract

TOP Abstract Introduction Technique Results Discussion References

 
Multiple anastomotic suture lines in aortic aneurysm surgery are prone to bleeding. To improve hemostasis, a 15-mm-wide strip of native pericardium was used to reinforce all anastomotic suture lines. This technique was used in 4 consecutive patients who underwent modified Bentall and elephant trunk procedures for extensive aortic aneurysm. The mean cardiopulmonary bypass time was 230 minutes and the mean aortic crossclamp time was 92 minutes. Mean blood loss through the mediastinal drainage tubes was 193 mL in the first 12 hours postoperatively and the mean blood requirement was 3 units. It was concluded that this technique markedly improved hemostasis in extensive aortic aneurysm surgery.

	Introduction

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Despite remarkable advances in surgical technique and postoperative care, bleeding from the anastomotic suture lines in aortic aneurysm surgery remains a major challenge.^1,2 It is often associated with increased morbidity, mortality, use of blood and blood products, and cost.^2,3 Several strategies have been devised to improve hemo-stasis but they have fallen into disrepute because of associated complications and limited applications.^4,5 However, the use of biological glue and collagen-impregnated Dacron grafts has been shown to significantly reduce postoperative bleeding in thoracic aneurysm repair.³ Others have used a piece of Dacron or Teflon and pedicled pericardium to wrap the aortic anastomosis to reduce stress on suture lines and decrease bleeding.⁵ This report describes a technique using a strip of native pericardium to reinforce all anastomotic suture lines.

	Technique

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Before initiation of cardiopulmonary bypass, multiple 15-mm-wide strips of native pericardium are excised and sutured around all proximal and distal ends of the vascular prosthesis in a continuous manner using 4/0 polypropylene suture. The ascending aorta is opened longitudinally. A small (8 to 10 mm) cuff of the aortic wall containing the coronary ostia is excised. The remaining aorta is transected proximally, leaving a 4 to 5 mm wide margin above the annulus. U-shaped horizontal interrupted mattress sutures are placed on the aorta in ventricular orientation through the annulus and passed through the sewing rim of the valvular prosthesis and the pericardial-wrapped proximal end of the vascular graft (Figure l). Both prostheses are seated at the annulus and the sutures are tied. The wrapped pericardium is unfolded and sutured with the cut end of the remaining proximal aorta, using 4/0 polypropylene suture in a continuous manner. At the conclusion of the distal anastomosis, the pericardium is again sutured to the wall of the native aorta. If necessary, arch vessels at the implantation site can be reinforced with pericardium in a similar manner.

View larger version (185K): [in this window] [in a new window]   Figure 1. View of valve sutures being brought out from the aortic annulus through the prosthetic valve and pericardial-reinforced vascular prosthesis.

	Results

TOP Abstract Introduction Technique Results Discussion References

 
This technique required an additional 3 to 5 minutes on bypass to bolster each anastomosis. Neither impregnated vascular grafts, wrapping of the prosthesis with native aorta or pedicled pericardium, biological glue, aprotinin, nor a cell saver were used in this study. The mean cardiopulmonary bypass time was 230 minutes and the mean aortic crossclamp time was 92 minutes. In the first 12 hours postoperatively, mean blood loss through the mediastinal drainage tube was 193 mL and the mean blood requirement was 3 units. One patient who had dissection of the aorta secondary to atherosclerosis, died on the 6th postoperative day because of persistent hypoxia due to chronic obstructive lung disease. The 3 survivors are currently in New York Heart Association functional class I and are on regular oral anticoagulants.

	Discussion

TOP Abstract Introduction Technique Results Discussion References

 
Since the introduction of composite valve grafts, replace-ment of the aortic root has become the standard procedure of choice for management of aneurysmal disease of the aortic root and type-A dissection involving the aortic valve.^1,2 However, anastomotic suture-line bleeding remains a major problem.^2,4 This technique, in which all the proximal and distal anastomotic suture lines are reinforced with native free pericardium, substantially improves hemostasis in two ways. Firstly, pericardium covering the vascular prosthesis acts as a pledget that plugs suture line holes and secures water-tight anasto-mosis. Secondly, pericardium sutured to the native aorta completely bolsters the anastomotic suture lines. Earlier, pericardium was used as a strip to sandwich the dissected layers of aorta between the outside and inside and thus reduce leaks into the false lumen through needle holes in the inner layer.⁶ Others have used pericardium as a pedicle graft to cover the prosthesis and anastomosis with the help of glue.⁵ In fact, the Bentall technique originally included graft wrapping by the tightly sutured native aorta to improve hemostasis, the so-called inclusion technique has been progressively abandoned by others.⁴ Bleeding into the space between the wrap and the prosthesis causes compression of the coronary anastomosis leading to dehiscence, false aneurysm, and prosthetic valve dysfunction.⁴ Other surgeons have constructed an aorto-right atrial shunt to decompress the hematoma.⁷ Use of biological glue and collagen-impregnated Dacron grafts was found to significantly reduce postoperative bleeding from thoracic aneurysm repair.⁸

We believe pericardial reinforcement of all anastomotic suture lines significantly improves hemostasis in aortic aneurysm surgery. This technique is very easy and safe and could be widely applied in the future to reduce complications.

	References

TOP Abstract Introduction Technique Results Discussion References

 

1. Bentall HH, DeBono A. A technique for complete replacement of ascending aorta. Thorax 1968;23:338–9.[Abstract/Free Full Text]

2. Gott VL, Gillinov AM, Pyeritz RE, Cameron DE, Reitz BA, Greene PS, et al. Aortic root replacement. Risk factor analysis of a seventeen-year experience with 270 patients. J Thorac Cardiovasc Surg 1995;109:536–44.[Abstract/Free Full Text]

3. Copeland JG III, Rosado LJ, Snyder SL. New technique for improving hemostasis in aortic root replacement with composite graft. Ann Thorac Surg 1993;55:1027–9.[Abstract]

4. Kouchoukos NT, Wareing TH, Murphy SF, Perrillo JB. Sixteen-year experience with aortic root replacement: result of 172 operations. Ann Surg 1991;214:308–20.[Medline]

5. Popoff GA, Diaz FO. Wrapping of aortic grafts by pedicled pericardial flaps. Ann Thorac Surg 1994;57:1346–8.[Abstract]

6. Ergin MA, Phillips RA, Galla JD, Lansman SL, Mendelson DS, Quintana CS, et al. Significance of distal false lumen after type A dissection repair. Ann Thorac Surg 1994; 57:820–5.[Abstract]

7. Cabrol C, Gandjbakhch I, Pavie A. Surgical treatment of ascending aortic pathology. J Card Surg 1988;3:167–80.[Medline]

8. Bachet J, Goudot B, Dreyfus G, Banfi C, Ayle NA, Aota M, et al. The proper use of glue: a 20-year experience with the GRF glue in acute aortic dissection. J Card Surg 1997;12(2 Suppl):243–53.[Medline]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Srivastava, A. K Articles by Kapoor, A. Search for Related Content PubMed Articles by Srivastava, A. K Articles by Kapoor, A.