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Reversed bevel technique for anastomosis at the aortic arch
Reversed Bevel Technique for Anastomosis at the Aortic Arch P a s a l a S. R a v i c h a n d r a n , M D , H . S t o r m F l o t e n , M D , J e f f r e y S. S w a n s o n , M D , H u g h L. G a t e l y , M D , H a g o p H o v a g u i m i a n , M D , A n t h o n y P. F u r n a r y , M D , a n d A l b e r t S t a r r , ME) The Heart Institute at Providence St. Vincent Medical Center, and Department of Cardiothoracic Surgery, Veterans' Affairs Medical Center, Portland, Oregon
We describe a method for performing the distal anastomosis in replacement of the ascending and the proximal arch of the aorta with specLfic attention to obtaining accurate length and orientation of the graft. This method reduces the incidence of both anastomotic dehiscence due to tension and obstruction caused by redundant graft. (Ann Thorac Surg 1996;61:245-0
raft replacement of the ascending and proximal arch of the aorta is performed frequently for aneurysms and type A dissection. The operative technique involves use of a single or two separate grafts for distal and proximal anastomoses. With a single graft, estimation of the graft length is di~cult due to the distortion of anatomy by the aortic disease process. It is further complicated by the fact that the distal anastomosis, performed at the undersurface of the arch, is elliptical and therefore requires beveling of the graft. We describe a method of accurate measuring, trimming, and beveling a single graft for the distal anastomosis.
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marker. This maneuver leaves a long tongue of graft anteriorly toward the innominate artery. Suturing is then begun on the posterior aspect of the distal aortic resection and continues along the right and left sides toward the innominate artery end of the anastomosis (Fig 2). Excess graft is trimmed as the anastomosis is being completed (Fig 3). The aorta is deaired as the circulation is resumed and the operation is finished in the usual manner. Comment
Measurement and trimming of the graft begins with an understanding of two important anatomic features of the ascending aorta and the arch. First, the length of the ascending aorta is variable, being longer anterolaterally and shorter posteromediaUy between the aortic valve and the undersurface of the arch. Second, the aortic arch
Technique In type A dissection and diffuse fusiform ascending aortic aneurysm the inner curve of the aortic arch to the level of the left subclavian artery is included in the aortic resection [1, 2]. The proximal anastomosis of the graft is completed first, followed by the distal anastomosis, which is routinely performed with open technique under circulatory arrest using right atriofemoral cardiopulmonary bypass. A long straight vascular clamp is applied on the graft in the coronal plane separating it into anterior and posterior halves. The graft is then held taut and marked with a suture posteriorly at a level adjacent to the left subclavian artery origin. This marker suture should also line up on the vertical plane with the left coronary artery ostium (Fig 1). The posterior half of the distal graft is then removed by trimming vertically down behind the clamp to the suture Acceptedfor publicationSep 11, 1995 Address reprint requests to Dr Floten, 9155 SW Barnes Rd, Suite 240, Portland, OR 97225. © 1996 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Fig 1. (A) Lateral view: the distance between the aortic annulus and the posterior extent of the aortic resection line (A-B) is less than the distance between the annulus and the anterior extent of the aortic resection line (C-D). (B) The long straight vascular clamp holds the distal graft taut and separates it into anterior and posterior halves. A marking suture is placed posteriorly in line with the aortic resection margin at the level of the left subclavian artery origin.
0003-4975/96/$15.00 SSDI 0003-4975(95)00910-8
246
HOW TO DO IT RAVICHANDRAN ET AL REVERSED BEVEL ANASTOMOSIS
Ann Thorac Surg 1996;61:245-6
2
Fig 3. The excess graft anteriorly is trimmed o~ as the anastomosis is completed. Fig 2. Suturing is begun on the posterior aspect of the aortic resection margin. A long tongue of excess graft is left anteriorly to accommodate the variable distance.
is mainly oriented anteroposteriorly and courses slightly from right to left. Using the aortic valve, the left subclavian artery origin, and the innominate artery as consistent landmarks, it should be possible to visualize that the bevel at the distal end of the graft should be directed anteriorly toward the origin of the innominate artery to accommodate the greater distance. Leaving a tongue of graft anteriorly also allows for the variable distance between the aortic valve and the innominate artery origin caused by the aortic disease process. Accurate measurement and orientation of the graft is simplified by using anatomic landmarks, which avoids producing either tension from a short graft or kinks from a redundant one. Although the reverse bevel technique is in contrast to the usual technique of anastomosis in this area, it has
been discussed previously by other authors [3]. Since 1986 we have used this technique in more than 65 patients o p e r a t e d on for type A aortic dissection, Marfan's syndrome, a n d atherosclerotic aneurysms. There was no incidence of perioperative anastomotic dehiscence or obstruction.
References 1. Massimo CG, Presenti LF, Favi PP, et al. Excision of the aortic wail in the surgical treatment of acute type A aortic dissection. Ann Thorac Surg 1990.,50..274-6. 2. Crawford ES, Svensson L, Coselli J, Sail HJ, Hess KR. Surgical treatment of aneurysm and/or dissection of the ascending aorta, transverse aortic arch and ascending aorta and transverse aortic arch. J Thorac Cardiovasc Surg 1989;98:659-74. 3. Griepp RB. Panel discussion. Semin Thorac Cardiovasc Surg 1991;3:215-8.
We describe a method for performing the distal anastomosis in replacement of the ascending and the proximal arch of the aorta with specLfic attention to obtaining accurate length and orientation of the graft. This method reduces the incidence of both anastomotic dehiscence due to tension and obstruction caused by redundant graft. (Ann Thorac Surg 1996;61:245-0
raft replacement of the ascending and proximal arch of the aorta is performed frequently for aneurysms and type A dissection. The operative technique involves use of a single or two separate grafts for distal and proximal anastomoses. With a single graft, estimation of the graft length is di~cult due to the distortion of anatomy by the aortic disease process. It is further complicated by the fact that the distal anastomosis, performed at the undersurface of the arch, is elliptical and therefore requires beveling of the graft. We describe a method of accurate measuring, trimming, and beveling a single graft for the distal anastomosis.
G
marker. This maneuver leaves a long tongue of graft anteriorly toward the innominate artery. Suturing is then begun on the posterior aspect of the distal aortic resection and continues along the right and left sides toward the innominate artery end of the anastomosis (Fig 2). Excess graft is trimmed as the anastomosis is being completed (Fig 3). The aorta is deaired as the circulation is resumed and the operation is finished in the usual manner. Comment
Measurement and trimming of the graft begins with an understanding of two important anatomic features of the ascending aorta and the arch. First, the length of the ascending aorta is variable, being longer anterolaterally and shorter posteromediaUy between the aortic valve and the undersurface of the arch. Second, the aortic arch
Technique In type A dissection and diffuse fusiform ascending aortic aneurysm the inner curve of the aortic arch to the level of the left subclavian artery is included in the aortic resection [1, 2]. The proximal anastomosis of the graft is completed first, followed by the distal anastomosis, which is routinely performed with open technique under circulatory arrest using right atriofemoral cardiopulmonary bypass. A long straight vascular clamp is applied on the graft in the coronal plane separating it into anterior and posterior halves. The graft is then held taut and marked with a suture posteriorly at a level adjacent to the left subclavian artery origin. This marker suture should also line up on the vertical plane with the left coronary artery ostium (Fig 1). The posterior half of the distal graft is then removed by trimming vertically down behind the clamp to the suture Acceptedfor publicationSep 11, 1995 Address reprint requests to Dr Floten, 9155 SW Barnes Rd, Suite 240, Portland, OR 97225. © 1996 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Fig 1. (A) Lateral view: the distance between the aortic annulus and the posterior extent of the aortic resection line (A-B) is less than the distance between the annulus and the anterior extent of the aortic resection line (C-D). (B) The long straight vascular clamp holds the distal graft taut and separates it into anterior and posterior halves. A marking suture is placed posteriorly in line with the aortic resection margin at the level of the left subclavian artery origin.
0003-4975/96/$15.00 SSDI 0003-4975(95)00910-8
246
HOW TO DO IT RAVICHANDRAN ET AL REVERSED BEVEL ANASTOMOSIS
Ann Thorac Surg 1996;61:245-6
2
Fig 3. The excess graft anteriorly is trimmed o~ as the anastomosis is completed. Fig 2. Suturing is begun on the posterior aspect of the aortic resection margin. A long tongue of excess graft is left anteriorly to accommodate the variable distance.
is mainly oriented anteroposteriorly and courses slightly from right to left. Using the aortic valve, the left subclavian artery origin, and the innominate artery as consistent landmarks, it should be possible to visualize that the bevel at the distal end of the graft should be directed anteriorly toward the origin of the innominate artery to accommodate the greater distance. Leaving a tongue of graft anteriorly also allows for the variable distance between the aortic valve and the innominate artery origin caused by the aortic disease process. Accurate measurement and orientation of the graft is simplified by using anatomic landmarks, which avoids producing either tension from a short graft or kinks from a redundant one. Although the reverse bevel technique is in contrast to the usual technique of anastomosis in this area, it has
been discussed previously by other authors [3]. Since 1986 we have used this technique in more than 65 patients o p e r a t e d on for type A aortic dissection, Marfan's syndrome, a n d atherosclerotic aneurysms. There was no incidence of perioperative anastomotic dehiscence or obstruction.
References 1. Massimo CG, Presenti LF, Favi PP, et al. Excision of the aortic wail in the surgical treatment of acute type A aortic dissection. Ann Thorac Surg 1990.,50..274-6. 2. Crawford ES, Svensson L, Coselli J, Sail HJ, Hess KR. Surgical treatment of aneurysm and/or dissection of the ascending aorta, transverse aortic arch and ascending aorta and transverse aortic arch. J Thorac Cardiovasc Surg 1989;98:659-74. 3. Griepp RB. Panel discussion. Semin Thorac Cardiovasc Surg 1991;3:215-8.