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A new method for graft tailoring in hemiarch replacement
A New Method for Graft Tailoring in Hemiarch Replacement Norihiko Shiiya, MD, PhD, and Keishu Yasuda, MD, PhD Department of Cardiovascular Surgery, Hokkaido University Hospital, Sapporo, Japan
We describe a method of graft tailoring in hemiarch replacement that can accommodate long elliptical distal anastomosis and the right angle between the arch and ascending aorta without kinks, resulting in a more physiologic shape of the neoaorta. The distal end of the graft is beveled superiorly, to spare the origins of brachiocephalic vessels as in the standard bevel technique, but the
incision line is curvilinear to form a concave cut end. Once the distal anastomosis is completed and the concavity of the cut end is straightened, the undersurface of the graft tongue forms a lesser curvature of the arch.
G
tions is elliptical and therefore requires beveling of the graft. With a single graft, the standard bevel technique may result in kinks because of the right angle between the arch and the ascending aorta [1]. To avoid this problem, the reversed bevel technique has been proposed by several authors [1, 2]. In this technique, however, the tongue of the graft at the base of the innominate artery may form a hornlike protrusion (Fig 1), when a markedly oblique anastomosis is made in the arch. Longterm outcome of such protrusion remains unknown. We describe a method of graft tailoring that can accommodate long elliptical distal anastomosis and the right angle between the arch and the ascending aorta without kinks or protrusion, resulting in a more physiologic shape of the neoaorta.
Fig 1. Magnetic resonance angiography of a patient after the reversed bevel technique. Note the hornlike protrusion at the base of the innominate artery. Accepted for publication Aug 19, 2003. Address reprint requests to Dr Shiiya, Department of Cardiovascular Surgery, Hokkaido University Hospital, N14W5, Kita-ku, Sapporo 0608648, Japan; e-mail: [email protected].
© 2004 by The Society of Thoracic Surgeons Published by Elsevier Inc
Fig 2. The concept of the new technique. The angle between the anastomotic plane and the ascending aortic graft is accommodated by the angle A. 0003-4975/04/$30.00 doi:10.1016/j.athoracsur.2003.08.043
FEATURE ARTICLES
raft replacement of the ascending aorta and the concavity of the arch, often termed hemiarch replacement, is performed frequently for aneurysms and aortic dissection. The distal anastomosis in such opera-
(Ann Thorac Surg 2004;78:1105– 6) © 2004 by The Society of Thoracic Surgeons
1106
HOW TO DO IT SHIIYA AND YASUDA GRAFT TAILORING IN HEMIARCH REPLACEMENT
Ann Thorac Surg 2004;78:1105– 6
Technique The distal anastomosis is performed first. The distal end of the graft is beveled superiorly to spare the origins of brachiocephalic vessels, as in the standard bevel technique, but the incision line is curvilinear to form a concave cut end (Fig 2). Before suturing is commenced, it is verified that the circumference of the cut end fits the anastomotic length. Suturing is then begun on the posterior aspect of the distal aortic resection toward the innominate artery end. After suturing on the anterior aspect is completed, the graft is clamped and systemic perfusion is resumed through the graft. The proximal anastomosis is performed during rewarming.
Comment
FEATURE ARTICLES
The rationale of this graft design is to create a more physiologic shape of the neoaorta, while kinks are avoided. The angle between the anastomotic plane and the ascending aortic graft is accommodated by angle A in Figure 2. Once the distal anastomosis is completed and the concavity of the cut end is straightened, the undersurface of the graft tongue is, in turn, bent to form a lesser curvature of the aortic arch. Using this graft design, the first author has performed 7 operations during the last 2 year-and-9-month period. The patients’ ages ranged from 51 to 82 (mean, 70) years. Four patients had type A aortic dissection (3 acute) and 3 had a degenerative aneurysm (1 due to Takayasu arteritis). The patient with Takayasu arteritis underwent Bentall operation (Fig 3) and a patient with bicuspid aortic valve underwent aortic valve repair concomitantly. All 7 operations were performed under deep hypothermic circulatory arrest and selective antegrade cerebral perfusion. Postoperative course was uneventful in every patient, and no complication was so far noted during the follow-up period.
References Fig 3. Three-dimensional computed tomographic scan in a patient after combined Bentall operation and hemiarch replacement using the new technique. Note that the lesser curvature of the aortic arch is formed by the graft (white line).
1. Borst HG, Heinemann MK, Stone CD. Proximal aortic dissection. In: Borst HG, ed. Surgical treatment of aortic dissection. New York: Churchill Livingstone, 1996:168. 2. Ravichandran PS, Floten HS, Swanson JS, et al. Reversed bevel technique for anastomosis at the aortic arch. Ann Thorac Surg 1996;61:245–6.
We describe a method of graft tailoring in hemiarch replacement that can accommodate long elliptical distal anastomosis and the right angle between the arch and ascending aorta without kinks, resulting in a more physiologic shape of the neoaorta. The distal end of the graft is beveled superiorly, to spare the origins of brachiocephalic vessels as in the standard bevel technique, but the
incision line is curvilinear to form a concave cut end. Once the distal anastomosis is completed and the concavity of the cut end is straightened, the undersurface of the graft tongue forms a lesser curvature of the arch.
G
tions is elliptical and therefore requires beveling of the graft. With a single graft, the standard bevel technique may result in kinks because of the right angle between the arch and the ascending aorta [1]. To avoid this problem, the reversed bevel technique has been proposed by several authors [1, 2]. In this technique, however, the tongue of the graft at the base of the innominate artery may form a hornlike protrusion (Fig 1), when a markedly oblique anastomosis is made in the arch. Longterm outcome of such protrusion remains unknown. We describe a method of graft tailoring that can accommodate long elliptical distal anastomosis and the right angle between the arch and the ascending aorta without kinks or protrusion, resulting in a more physiologic shape of the neoaorta.
Fig 1. Magnetic resonance angiography of a patient after the reversed bevel technique. Note the hornlike protrusion at the base of the innominate artery. Accepted for publication Aug 19, 2003. Address reprint requests to Dr Shiiya, Department of Cardiovascular Surgery, Hokkaido University Hospital, N14W5, Kita-ku, Sapporo 0608648, Japan; e-mail: [email protected].
© 2004 by The Society of Thoracic Surgeons Published by Elsevier Inc
Fig 2. The concept of the new technique. The angle between the anastomotic plane and the ascending aortic graft is accommodated by the angle A. 0003-4975/04/$30.00 doi:10.1016/j.athoracsur.2003.08.043
FEATURE ARTICLES
raft replacement of the ascending aorta and the concavity of the arch, often termed hemiarch replacement, is performed frequently for aneurysms and aortic dissection. The distal anastomosis in such opera-
(Ann Thorac Surg 2004;78:1105– 6) © 2004 by The Society of Thoracic Surgeons
1106
HOW TO DO IT SHIIYA AND YASUDA GRAFT TAILORING IN HEMIARCH REPLACEMENT
Ann Thorac Surg 2004;78:1105– 6
Technique The distal anastomosis is performed first. The distal end of the graft is beveled superiorly to spare the origins of brachiocephalic vessels, as in the standard bevel technique, but the incision line is curvilinear to form a concave cut end (Fig 2). Before suturing is commenced, it is verified that the circumference of the cut end fits the anastomotic length. Suturing is then begun on the posterior aspect of the distal aortic resection toward the innominate artery end. After suturing on the anterior aspect is completed, the graft is clamped and systemic perfusion is resumed through the graft. The proximal anastomosis is performed during rewarming.
Comment
FEATURE ARTICLES
The rationale of this graft design is to create a more physiologic shape of the neoaorta, while kinks are avoided. The angle between the anastomotic plane and the ascending aortic graft is accommodated by angle A in Figure 2. Once the distal anastomosis is completed and the concavity of the cut end is straightened, the undersurface of the graft tongue is, in turn, bent to form a lesser curvature of the aortic arch. Using this graft design, the first author has performed 7 operations during the last 2 year-and-9-month period. The patients’ ages ranged from 51 to 82 (mean, 70) years. Four patients had type A aortic dissection (3 acute) and 3 had a degenerative aneurysm (1 due to Takayasu arteritis). The patient with Takayasu arteritis underwent Bentall operation (Fig 3) and a patient with bicuspid aortic valve underwent aortic valve repair concomitantly. All 7 operations were performed under deep hypothermic circulatory arrest and selective antegrade cerebral perfusion. Postoperative course was uneventful in every patient, and no complication was so far noted during the follow-up period.
References Fig 3. Three-dimensional computed tomographic scan in a patient after combined Bentall operation and hemiarch replacement using the new technique. Note that the lesser curvature of the aortic arch is formed by the graft (white line).
1. Borst HG, Heinemann MK, Stone CD. Proximal aortic dissection. In: Borst HG, ed. Surgical treatment of aortic dissection. New York: Churchill Livingstone, 1996:168. 2. Ravichandran PS, Floten HS, Swanson JS, et al. Reversed bevel technique for anastomosis at the aortic arch. Ann Thorac Surg 1996;61:245–6.