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A Novel Arch-First T-Graft Technique for Extensive Aortic Arch Reconstruction
HOW TO DO IT
A Novel Arch-First T-Graft Technique for Extensive Aortic Arch Reconstruction Shih-Rong Hsieh, MD, Chien-Chang Chen, MD, and Hao-Ji Wei, MD Cardiovascular Center of Taichung Veterans General Hospital, Taichung City, Division of Cardiovascular Surgery of Chi-Mei Hospital, Yungkang City, Tainan County, National Yang Ming University School of Medicine, Taipei, Taiwan
FEATURE ARTICLES
To reduce the morbidity and mortality associated with extensive aortic arch replacement, the reconstruction technique is the most important part of the treatment. By refining the present techniques, we developed an archfirst T-graft technique. This technique provides a more reasonable arrangement of procedures, least brain ischemic time, less low-body ischemic time, and an easy way
of distal aortic anastomosis. This method is performed through a traditional median sternotomy, keeps the lung free from manipulation, and avoids severe kink of major vascular grafts.
A
during the operation, then a two-stage venous cannula was placed in the right atrium, and a retrograde cardioplegia catheter was placed in the coronary sinus. The left ventricle was decompressed from the right superior pulmonary vein. The patients were placed on cardiopulmonary bypass and gradually cooled. When the nasopharyngeal temperature reaches 22°C, the brachiocephalic artery was clamped softly on both sides with atraumatic clamps under transiently decreased bypass flow. The artery was transected with the proximal stump closed with a running suture. An Ultramax Y-graft (Atrium Medical, Hudson, NH) of suitable size was used for reconstruction. One of the lesser limbs of the Y-graft was trimmed and anastomosed to the brachiocephalic artery with a 5-0 polypropylene running suture (Fig 1A). After careful evacuation of air, the Y-graft was clamped tangentially between the two lesser limbs of the Y-graft and the right side cerebral perfusion was continued from the right axillary arterial cannula or a side branch on the Y-graft that had been prepared beforehand. The left common carotid artery was clamped on both sides with atraumatic clamps. Full bypass flow was maintained to keep the right radial arterial pressure above 50 mm Hg. The left common carotid artery was transected with the proximal stump oversewn. The left lesser limb of the Y-graft was trimmed and anastomosed to the left common carotid artery (Fig 1B). After the anastomoses, the clamp was moved to the main trunk. Perfusion to the above two reconstructed supra-aortic arteries was continued through the right axillary arterial cannula or the side branch of the Y-graft (Fig 1C). The ascending aorta was cross-clamped and the myocardium was protected by antegrade and retrograde blood cardioplegia perfusion. Lower body perfusion from the common femoral artery was stopped when the core temperature reached 16 to 18°C and the perfusion flow through the right axillary cannula was kept at approximately 15 to 20 mL/Kg/min to maintain right radial arterial pressure at approximately 50 to 60 mm Hg. The
neurysmal disease and associated atherosclerotic degenerative change are rarely isolated in the transverse arch segment. The terms extensive aortic arch aneurysm are used to describe those aneurysms that involve the ascending aorta, the arch, the brachiocephalic vessels, and a segment of the descending aorta. Treating this disease remains a great challenge. We recently developed a “T-graft” technique for extensive aortic arch replacement, which is divided into three components: (1) reconstruction of the brachiocephalic and left common carotid arteries with a Y-vascular graft during hypothermic circulatory arrest or a partial brain ischemic period [1], (2) reconstruction of the descending aorta using a reversed vascular technique [2], and (3) reconstruction of the left subclavian artery. This technique decreases brain ischemic time, facilitates secure anastomosis of the deep aorta, and avoids kinking of a long aortic graft.
Technique Patients with aneurysms and severe atherosclerotic change involving their ascending aorta, arch, and proximal portion of the descending aorta were candidates of this procedure. The standard median sternotomy was performed. Patients were administered with heparin and an 8-mm to 10-mm Dacron graft (Dupont, Wilmington, DE) were anastomosed end-to-side to one femoral artery and another 8-mm to 10-mm Dacron graft (DuPont) anastomosed to the right axillary artery as a side graft. Two 24-French flexible arterial cannulas (Terumo, Ann Arbor, MI) were inserted into these two side grafts and fixed in position as arterial inflow routes, so perfusion of the distal part of the limbs could be saved and the right radial arterial pressure could be constantly monitored Accepted for publication Nov 9, 2007. Address correspondence to Dr Wei, Cardiovascular Center of Taichung Veterans General Hospital, 160 Taichung-Kang 3rd Rd, Taichung City, 40705, Taiwan; e-mail: [email protected].
© 2008 by The Society of Thoracic Surgeons Published by Elsevier Inc
(Ann Thorac Surg 2008;85:1814 – 6) © 2008 by The Society of Thoracic Surgeons
0003-4975/08/$34.00 doi:10.1016/j.athoracsur.2007.11.026
HOW TO DO IT HSIEH ET AL ARCH-FIRST T-GRAFT
1815
ascending aorta and aortic arch were opened longitudinally. A clamp was placed on the left subclavian artery to prevent pressure leak of the perfused cerebral system. To reconstruct the distal thoracic aorta, a straight Ultramax graft (Atrium Medical) was chosen according to the diameter of a normal descending aorta. Usually, this anastomosis was the most difficult part of the operation. To simplify the deep distal aortic anastomosis, we used the “reversed vascular graft” technique [2]. Briefly, an inside-out reversed sleeve graft was made and was inserted into the distal aorta after being folded along the longitudinal axis (Fig 1C). The anastomosis was done using double rows of 3-0 polypropylene running suture. It usually takes approximately 30 minutes and occasionally 40 minutes or more for a difficult anastomosis. After completion of the anastomosis, the invaginated graft was pulled out of the aortic lumen. The graft was clamped after evacuation of air and the lower body perfusion was restored. The patient was rewarmed. A separate, small straight vascular graft of appropriate size was directly anastomosed to the distal end of the left subclavian artery (Fig 1D). Sometimes this anastomosis is so difficult and time-consuming that it deserves the last priority. Alternatively, a later extra-anatomic reconstruction near the end of surgery can be a substitute. After completion of this anastomosis, the left subclavian arterial clamp was moved to this small graft and then the graft was left alone for later use (Fig 2A). To construct the aortic graft-to-graft anastomosis, the descending aortic graft was trimmed and beveled to an appropriate length and was anastomosed to a defect created on the left wall of a Y-graft trunk in an end-to-side manner using double rows of 3-0 polypropylene running sutures (Fig 1E). Finally, the proximal aortic anastomosis was performed (usually with a felt strip reinforcement), followed by anastomosing the left subclavian graft to an appropriate segment of the main graft with the aid of an aortic partial clamp (Figs 1F, 2B).
Comment Fig 1. (A) The right lesser limb of the Y-graft was anastomosed to the brachiocephalic artery using a running 5-0 polypropylene. The brain was perfused both from right axillary (dashed arrow) and femoral arterial inflow (blank arrow). (B) The left common carotid artery was transected with its proximal end oversewn. The right cerebral hemisphere was perfused from right axillary artery (slant-line arrow) or side-branch graft (black arrow). (C) The main trunk of the Y-graft and the left subclavian artery were clamped and the aorta was fully opened. A reversed vascular graft was inserted into the distal aorta and the anastomosis was made with 3-0 polypropylenes. The brain was fully protected with antegraft flow. (D) The reversed vascular graft was pulled out and clamped after evaculating air. Both upper and lower body perfusion restarted. A separate graft was anastomosed to the left subclavian artery. (E) The proximal end of the straight distal aortic graft was anastomosed to the left side-hole of the Y-graft. (F) The left subclavian graft was anastomosed to the straight distal aortic graft. The side-branch stump of the Y-graft was oversewn.
The T-graft technique evolved from the reversed vascular graft technique for the extensive arch replacement [2]. By combining the arch-first technique, the modification of trifurcated graft technique [1, 3] and the reversed vascular graft technique, a novel T-graft technique was developed to simplify extensive aortic arch repair. Actually, the method can be applied to most operations of total aortic arch replacement. We arrange the procedure into three parts according to the severity of ischemic impacts on different organs. Reconstruction of the brachiocephalic artery and the left common carotid artery has the highest priority and is done first. Owing to the smaller size of these vessels, the conduction of anastomosis is easier and risk of bleeding is lesser as compared with the conventional island technique. Reconstruction of the proximal descending thoracic aorta has the second priority. Performing a deep aortic anastomosis is not an easy task. Difficult anastomosis prolongs the lower body ischemic time and increases the possibility of lethal bleeding. That is why we prefer to do this anastomosis
FEATURE ARTICLES
Ann Thorac Surg 2008;85:1814 – 6
1816
HOW TO DO IT HSIEH ET AL ARCH-FIRST T-GRAFT
Ann Thorac Surg 2008;85:1814 – 6
Fig 2. (A) Completion of anastomoses of the three supra-aortic arteries and the distal aorta from the surgeon’s view. (B) Intraoperative view of the completion of the T-graft.
FEATURE ARTICLES
under deep hypothermia. With the aid of reversed vascular graft technique, the aortic anastomosis becomes easier and safer than before. The reversed vascular graft technique provides a good visual field, meticulously secured sutures, and a check-valve effect to prevent leakage. Reconstruction of the left subclavian artery has the last priority. We usually performed this procedure during the rewarming period. The T-graft technique can be easily performed through a median sternotomy. Working inside of the aortic lumen prevents pulmonary bleeding caused by inevitable manipulation of the lung through thoracotomy. This approach also provides ample myocardial and cerebral protection, as well as excellent exposure for concomitant cardiac procedures. Compared with the method described earlier [1], another advantage of the T-graft technique is a more reasonable arrangement of the graft. By reconstructing the ascending aorta with the Y-graft instead of the graft from the descending aorta, this T-graft technique keeps the arch portion in a nature curved in a horizontal direction and prevents undue graft kink as well as associated tension on anastomosis. From July 2002 to June 2007, 11 patients underwent extensive aortic arch repair with the arch-first T-graft technique. There were 8 men and 3 women with a mean age of 70.3 years (range, 53 to 79 years). In fact, reconstructions of the supra-aortic branches were performed under deep hypothermic total circulatory arrest with retrograde cerebral perfusion in 8 of 11 patients (espe-
cially in the early 7 patients). The other 3 patients were operated on with the present technique. The recent criteria for right axillary artery cannulation depend on the quality of this vessel. There were two early deaths in these 11 patients. One 72-year-old man with uremia died of postoperative coagulopathy and heart failure. Another 79-year-old woman who had uremia and infected arch aneurysm expired postoperatively, due to multiple organ failure. Two of 11 patients required re-entry for postoperative hemorrhage. Pneumonia developed in 3 patients (ie, 1 had a minor stroke and 2 had vocal cord paralysis, but they had preoperative hoarseness). No one had paraplegia or a deep wound infection. The T-graft technique provides a more reasonable arrangement of procedures, a least brain ischemic time, and an easy distal aortic anastomosis.
References 1. Chen CC, Hsieh SR. Modified trifurcated graft in acute type A aortic dissection with the least brain ischemic time. Ann Thorac Surg 2007;83:e6 – 8. 2. Hsieh SR, Verrier ED. A short wholly inside-out reversed vascular graft facilitating difficult aortic anastomosis. Ann Thorac Surg 2005;80:1534 – 6. 3. Spielvogel D, Strauch JT, Minanov OP, Lansman SL, Griepp RB. Aortic arch replacement using a trifurcated graft and selective cerebral antegrade perfusion. Ann Thorac Surg 2002;74(Supp):1810 – 4.
A Novel Arch-First T-Graft Technique for Extensive Aortic Arch Reconstruction Shih-Rong Hsieh, MD, Chien-Chang Chen, MD, and Hao-Ji Wei, MD Cardiovascular Center of Taichung Veterans General Hospital, Taichung City, Division of Cardiovascular Surgery of Chi-Mei Hospital, Yungkang City, Tainan County, National Yang Ming University School of Medicine, Taipei, Taiwan
FEATURE ARTICLES
To reduce the morbidity and mortality associated with extensive aortic arch replacement, the reconstruction technique is the most important part of the treatment. By refining the present techniques, we developed an archfirst T-graft technique. This technique provides a more reasonable arrangement of procedures, least brain ischemic time, less low-body ischemic time, and an easy way
of distal aortic anastomosis. This method is performed through a traditional median sternotomy, keeps the lung free from manipulation, and avoids severe kink of major vascular grafts.
A
during the operation, then a two-stage venous cannula was placed in the right atrium, and a retrograde cardioplegia catheter was placed in the coronary sinus. The left ventricle was decompressed from the right superior pulmonary vein. The patients were placed on cardiopulmonary bypass and gradually cooled. When the nasopharyngeal temperature reaches 22°C, the brachiocephalic artery was clamped softly on both sides with atraumatic clamps under transiently decreased bypass flow. The artery was transected with the proximal stump closed with a running suture. An Ultramax Y-graft (Atrium Medical, Hudson, NH) of suitable size was used for reconstruction. One of the lesser limbs of the Y-graft was trimmed and anastomosed to the brachiocephalic artery with a 5-0 polypropylene running suture (Fig 1A). After careful evacuation of air, the Y-graft was clamped tangentially between the two lesser limbs of the Y-graft and the right side cerebral perfusion was continued from the right axillary arterial cannula or a side branch on the Y-graft that had been prepared beforehand. The left common carotid artery was clamped on both sides with atraumatic clamps. Full bypass flow was maintained to keep the right radial arterial pressure above 50 mm Hg. The left common carotid artery was transected with the proximal stump oversewn. The left lesser limb of the Y-graft was trimmed and anastomosed to the left common carotid artery (Fig 1B). After the anastomoses, the clamp was moved to the main trunk. Perfusion to the above two reconstructed supra-aortic arteries was continued through the right axillary arterial cannula or the side branch of the Y-graft (Fig 1C). The ascending aorta was cross-clamped and the myocardium was protected by antegrade and retrograde blood cardioplegia perfusion. Lower body perfusion from the common femoral artery was stopped when the core temperature reached 16 to 18°C and the perfusion flow through the right axillary cannula was kept at approximately 15 to 20 mL/Kg/min to maintain right radial arterial pressure at approximately 50 to 60 mm Hg. The
neurysmal disease and associated atherosclerotic degenerative change are rarely isolated in the transverse arch segment. The terms extensive aortic arch aneurysm are used to describe those aneurysms that involve the ascending aorta, the arch, the brachiocephalic vessels, and a segment of the descending aorta. Treating this disease remains a great challenge. We recently developed a “T-graft” technique for extensive aortic arch replacement, which is divided into three components: (1) reconstruction of the brachiocephalic and left common carotid arteries with a Y-vascular graft during hypothermic circulatory arrest or a partial brain ischemic period [1], (2) reconstruction of the descending aorta using a reversed vascular technique [2], and (3) reconstruction of the left subclavian artery. This technique decreases brain ischemic time, facilitates secure anastomosis of the deep aorta, and avoids kinking of a long aortic graft.
Technique Patients with aneurysms and severe atherosclerotic change involving their ascending aorta, arch, and proximal portion of the descending aorta were candidates of this procedure. The standard median sternotomy was performed. Patients were administered with heparin and an 8-mm to 10-mm Dacron graft (Dupont, Wilmington, DE) were anastomosed end-to-side to one femoral artery and another 8-mm to 10-mm Dacron graft (DuPont) anastomosed to the right axillary artery as a side graft. Two 24-French flexible arterial cannulas (Terumo, Ann Arbor, MI) were inserted into these two side grafts and fixed in position as arterial inflow routes, so perfusion of the distal part of the limbs could be saved and the right radial arterial pressure could be constantly monitored Accepted for publication Nov 9, 2007. Address correspondence to Dr Wei, Cardiovascular Center of Taichung Veterans General Hospital, 160 Taichung-Kang 3rd Rd, Taichung City, 40705, Taiwan; e-mail: [email protected].
© 2008 by The Society of Thoracic Surgeons Published by Elsevier Inc
(Ann Thorac Surg 2008;85:1814 – 6) © 2008 by The Society of Thoracic Surgeons
0003-4975/08/$34.00 doi:10.1016/j.athoracsur.2007.11.026
HOW TO DO IT HSIEH ET AL ARCH-FIRST T-GRAFT
1815
ascending aorta and aortic arch were opened longitudinally. A clamp was placed on the left subclavian artery to prevent pressure leak of the perfused cerebral system. To reconstruct the distal thoracic aorta, a straight Ultramax graft (Atrium Medical) was chosen according to the diameter of a normal descending aorta. Usually, this anastomosis was the most difficult part of the operation. To simplify the deep distal aortic anastomosis, we used the “reversed vascular graft” technique [2]. Briefly, an inside-out reversed sleeve graft was made and was inserted into the distal aorta after being folded along the longitudinal axis (Fig 1C). The anastomosis was done using double rows of 3-0 polypropylene running suture. It usually takes approximately 30 minutes and occasionally 40 minutes or more for a difficult anastomosis. After completion of the anastomosis, the invaginated graft was pulled out of the aortic lumen. The graft was clamped after evacuation of air and the lower body perfusion was restored. The patient was rewarmed. A separate, small straight vascular graft of appropriate size was directly anastomosed to the distal end of the left subclavian artery (Fig 1D). Sometimes this anastomosis is so difficult and time-consuming that it deserves the last priority. Alternatively, a later extra-anatomic reconstruction near the end of surgery can be a substitute. After completion of this anastomosis, the left subclavian arterial clamp was moved to this small graft and then the graft was left alone for later use (Fig 2A). To construct the aortic graft-to-graft anastomosis, the descending aortic graft was trimmed and beveled to an appropriate length and was anastomosed to a defect created on the left wall of a Y-graft trunk in an end-to-side manner using double rows of 3-0 polypropylene running sutures (Fig 1E). Finally, the proximal aortic anastomosis was performed (usually with a felt strip reinforcement), followed by anastomosing the left subclavian graft to an appropriate segment of the main graft with the aid of an aortic partial clamp (Figs 1F, 2B).
Comment Fig 1. (A) The right lesser limb of the Y-graft was anastomosed to the brachiocephalic artery using a running 5-0 polypropylene. The brain was perfused both from right axillary (dashed arrow) and femoral arterial inflow (blank arrow). (B) The left common carotid artery was transected with its proximal end oversewn. The right cerebral hemisphere was perfused from right axillary artery (slant-line arrow) or side-branch graft (black arrow). (C) The main trunk of the Y-graft and the left subclavian artery were clamped and the aorta was fully opened. A reversed vascular graft was inserted into the distal aorta and the anastomosis was made with 3-0 polypropylenes. The brain was fully protected with antegraft flow. (D) The reversed vascular graft was pulled out and clamped after evaculating air. Both upper and lower body perfusion restarted. A separate graft was anastomosed to the left subclavian artery. (E) The proximal end of the straight distal aortic graft was anastomosed to the left side-hole of the Y-graft. (F) The left subclavian graft was anastomosed to the straight distal aortic graft. The side-branch stump of the Y-graft was oversewn.
The T-graft technique evolved from the reversed vascular graft technique for the extensive arch replacement [2]. By combining the arch-first technique, the modification of trifurcated graft technique [1, 3] and the reversed vascular graft technique, a novel T-graft technique was developed to simplify extensive aortic arch repair. Actually, the method can be applied to most operations of total aortic arch replacement. We arrange the procedure into three parts according to the severity of ischemic impacts on different organs. Reconstruction of the brachiocephalic artery and the left common carotid artery has the highest priority and is done first. Owing to the smaller size of these vessels, the conduction of anastomosis is easier and risk of bleeding is lesser as compared with the conventional island technique. Reconstruction of the proximal descending thoracic aorta has the second priority. Performing a deep aortic anastomosis is not an easy task. Difficult anastomosis prolongs the lower body ischemic time and increases the possibility of lethal bleeding. That is why we prefer to do this anastomosis
FEATURE ARTICLES
Ann Thorac Surg 2008;85:1814 – 6
1816
HOW TO DO IT HSIEH ET AL ARCH-FIRST T-GRAFT
Ann Thorac Surg 2008;85:1814 – 6
Fig 2. (A) Completion of anastomoses of the three supra-aortic arteries and the distal aorta from the surgeon’s view. (B) Intraoperative view of the completion of the T-graft.
FEATURE ARTICLES
under deep hypothermia. With the aid of reversed vascular graft technique, the aortic anastomosis becomes easier and safer than before. The reversed vascular graft technique provides a good visual field, meticulously secured sutures, and a check-valve effect to prevent leakage. Reconstruction of the left subclavian artery has the last priority. We usually performed this procedure during the rewarming period. The T-graft technique can be easily performed through a median sternotomy. Working inside of the aortic lumen prevents pulmonary bleeding caused by inevitable manipulation of the lung through thoracotomy. This approach also provides ample myocardial and cerebral protection, as well as excellent exposure for concomitant cardiac procedures. Compared with the method described earlier [1], another advantage of the T-graft technique is a more reasonable arrangement of the graft. By reconstructing the ascending aorta with the Y-graft instead of the graft from the descending aorta, this T-graft technique keeps the arch portion in a nature curved in a horizontal direction and prevents undue graft kink as well as associated tension on anastomosis. From July 2002 to June 2007, 11 patients underwent extensive aortic arch repair with the arch-first T-graft technique. There were 8 men and 3 women with a mean age of 70.3 years (range, 53 to 79 years). In fact, reconstructions of the supra-aortic branches were performed under deep hypothermic total circulatory arrest with retrograde cerebral perfusion in 8 of 11 patients (espe-
cially in the early 7 patients). The other 3 patients were operated on with the present technique. The recent criteria for right axillary artery cannulation depend on the quality of this vessel. There were two early deaths in these 11 patients. One 72-year-old man with uremia died of postoperative coagulopathy and heart failure. Another 79-year-old woman who had uremia and infected arch aneurysm expired postoperatively, due to multiple organ failure. Two of 11 patients required re-entry for postoperative hemorrhage. Pneumonia developed in 3 patients (ie, 1 had a minor stroke and 2 had vocal cord paralysis, but they had preoperative hoarseness). No one had paraplegia or a deep wound infection. The T-graft technique provides a more reasonable arrangement of procedures, a least brain ischemic time, and an easy distal aortic anastomosis.
References 1. Chen CC, Hsieh SR. Modified trifurcated graft in acute type A aortic dissection with the least brain ischemic time. Ann Thorac Surg 2007;83:e6 – 8. 2. Hsieh SR, Verrier ED. A short wholly inside-out reversed vascular graft facilitating difficult aortic anastomosis. Ann Thorac Surg 2005;80:1534 – 6. 3. Spielvogel D, Strauch JT, Minanov OP, Lansman SL, Griepp RB. Aortic arch replacement using a trifurcated graft and selective cerebral antegrade perfusion. Ann Thorac Surg 2002;74(Supp):1810 – 4.