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Ascending-Distal Aorta Bypass
CORRESPONDENCE
Ascending-Distal Aorta Bypass To the Editor:
Reply To the Editor:
I read with great interest the report by Robicsek and co-workers (Ann Thorac Surg 37261, 1984) about the treatment of complex coarctation by an extraanatomical bypass from the ascending aorta to the lower abdominal aorta. I have used the same principle in 2 similar patients, 1 in 1978 and 1 in 1979, although I chose to place the distal anastomosis in the chest. The entire procedure was accomplished through a standard right posterolateral thoracotomy. The proximal anastomosis was performed to the right side of the ascending aorta using a partial occluding clamp. The distal anastomosis was performed to the descending aorta just above the diaphragm. After division of the inferior pulmonary ligament, a portion of aorta was easily visualized and mobilized between the vertebral bodies posteriorly and the esophagus anteriorly. The distal anastomosis was easily constructed. The graft was allowed to loop gently anteriorly. I believe that this procedure is a better alternative for the treatment of a difficult problem and provides the advantages of simplicity and a marked decrease in the amount of dissection required. It also avoids the intraabdominal entry and the creation of a long retroperitoneal tunnel with potential complications such as hematomas and erosion in the pancreas and duodenum.
I certainly agree that an approach through the right chest provides a reasonable and safe alternative to a redo sternotomy for certain procedures, particularly, as Dr. Oropeza points out, operations on the atrioventricular valves. Perhaps Dr. Jain and I did not give this alternative enough emphasis in our paper but we did refer to it, and we use it on occasion. We thank Dr. Oropeza for drawing attention to this option.
Bechara F . Akl, M . D . Thoracic and Cardiovascular Division Department of Surgery University of N m Mexico School of Medicine 2211 Lomas Blvd, N E Albuquerque, N M 87131
Hemorrhage during Redo Sternotomy To the Editor: Dobell and Jain recently reviewed in The Annals (Ann Thorac Surg 37273, 1984) the attitude of 131 surgeons toward the performance of a second sternotomy and assessed 144 hemorrhages that occurred as the sternotomy was being done. My colleagues and I also see such complications, probably because the large majority of our patients undergoing reoperation have had rheumatic fever with extensive cardiomegaly that makes the right chambers of the heart prone to such injuries. However, I believe that such complications can be reduced if the heart is approached through a right anterolateral thoracotomy with femoral artery cannulation. The chest is entered through the fourth intercostal space with transection of the sternum; then, under direct vision, only the necessary dissection of the heart and great vessels is done. This approach offers excellent exposure of the mitral and tricuspid valves, and helps prevent the complications of redo stemotomy in this group of patients.
Germcin Oropeza, M . D Cardiovascular Surgery Service Centro Hospifalario ”20 de Noviembre” ISSSTE Av Cqoacan y Felix Cucvas Mexico DF, Mexico
196
A . R. C. Dobell, M.D. Division of Cardiovascular and Thoracic Surgey McGill University 2300 Tupper Montreal, PQ, Canada H3H lB3
Ethanol Vapor Entrapment under Drapes To the Editor: The hazards of using ethanol-based skin preparation solutions in the presence of diathermy are well known, particularly during operations on the perineum [l, 21. These solutions, however, are still widely used in general and thoracic surgery, since aqueous solutions have been found to be messy and inconvenient. The justification for this continuing practice is the belief that ethanol evaporates quickly from the skin so that none remains by the time the diathermy unit is used. In general, this is true. However, circumstances may easily arise whereby flammable concentrations of ethanol vapor become trapped under the drapes and remain there for considerable periods. Recently the drapes on a patient undergoing thoracotomy in our institution caught fire. This prompted us to examine the problem closely. We placed a volunteer in the right lateral position over a chest support, as for a thoracotomy. The skin was prepared using weak iodine solution BP (iodine, 1.23%; potassium iodide, 1.23%; ethanol, 88.9%). Then, the area was draped using a Johnson & Johnson Surgikos disposable paper barrier thoracic drape, followed by an adherent Steri-Drape applied after the skin was dry. A suction probe was immediately placed under the drape, and the ethanol concentration was measured using a mass spectrometer (Centronics 200 MGA medical gas analyzer) connected to a Rikadenki 3 pen recorder. The spectrometer was calibrated using a flask saturated with ethanol vapor at a known temperature [3]. With the probe beside the volunteer’s back, the maximum level of ethanol vapor recorded was 1.8% volivol (minimum flammable level, 3.28%vol/vol 131). When the probe was placed anteriorly above the chest support, the level rose to 3.2% voli vol and then declined to less than 2.3%vol/vol after 40 seconds. In a repeat experiment in which a folded towel was placed between the chest and the support and the iodine solution was allowed to soak into the towel, vapor concentration remained above the minimum flammable level for more than four minutes. In preparation of a curved skin surface, as for a thoracotomy, skin preparation solution can easily run down the front and back of the patient. If this solution soaks into any absorbent material, a fire risk exists for several minutes. This would be exacerbated by use of a type of drape that is relatively impervious to ethanol vapor and thereby retards vapor dispersal. Also,
Ascending-Distal Aorta Bypass To the Editor:
Reply To the Editor:
I read with great interest the report by Robicsek and co-workers (Ann Thorac Surg 37261, 1984) about the treatment of complex coarctation by an extraanatomical bypass from the ascending aorta to the lower abdominal aorta. I have used the same principle in 2 similar patients, 1 in 1978 and 1 in 1979, although I chose to place the distal anastomosis in the chest. The entire procedure was accomplished through a standard right posterolateral thoracotomy. The proximal anastomosis was performed to the right side of the ascending aorta using a partial occluding clamp. The distal anastomosis was performed to the descending aorta just above the diaphragm. After division of the inferior pulmonary ligament, a portion of aorta was easily visualized and mobilized between the vertebral bodies posteriorly and the esophagus anteriorly. The distal anastomosis was easily constructed. The graft was allowed to loop gently anteriorly. I believe that this procedure is a better alternative for the treatment of a difficult problem and provides the advantages of simplicity and a marked decrease in the amount of dissection required. It also avoids the intraabdominal entry and the creation of a long retroperitoneal tunnel with potential complications such as hematomas and erosion in the pancreas and duodenum.
I certainly agree that an approach through the right chest provides a reasonable and safe alternative to a redo sternotomy for certain procedures, particularly, as Dr. Oropeza points out, operations on the atrioventricular valves. Perhaps Dr. Jain and I did not give this alternative enough emphasis in our paper but we did refer to it, and we use it on occasion. We thank Dr. Oropeza for drawing attention to this option.
Bechara F . Akl, M . D . Thoracic and Cardiovascular Division Department of Surgery University of N m Mexico School of Medicine 2211 Lomas Blvd, N E Albuquerque, N M 87131
Hemorrhage during Redo Sternotomy To the Editor: Dobell and Jain recently reviewed in The Annals (Ann Thorac Surg 37273, 1984) the attitude of 131 surgeons toward the performance of a second sternotomy and assessed 144 hemorrhages that occurred as the sternotomy was being done. My colleagues and I also see such complications, probably because the large majority of our patients undergoing reoperation have had rheumatic fever with extensive cardiomegaly that makes the right chambers of the heart prone to such injuries. However, I believe that such complications can be reduced if the heart is approached through a right anterolateral thoracotomy with femoral artery cannulation. The chest is entered through the fourth intercostal space with transection of the sternum; then, under direct vision, only the necessary dissection of the heart and great vessels is done. This approach offers excellent exposure of the mitral and tricuspid valves, and helps prevent the complications of redo stemotomy in this group of patients.
Germcin Oropeza, M . D Cardiovascular Surgery Service Centro Hospifalario ”20 de Noviembre” ISSSTE Av Cqoacan y Felix Cucvas Mexico DF, Mexico
196
A . R. C. Dobell, M.D. Division of Cardiovascular and Thoracic Surgey McGill University 2300 Tupper Montreal, PQ, Canada H3H lB3
Ethanol Vapor Entrapment under Drapes To the Editor: The hazards of using ethanol-based skin preparation solutions in the presence of diathermy are well known, particularly during operations on the perineum [l, 21. These solutions, however, are still widely used in general and thoracic surgery, since aqueous solutions have been found to be messy and inconvenient. The justification for this continuing practice is the belief that ethanol evaporates quickly from the skin so that none remains by the time the diathermy unit is used. In general, this is true. However, circumstances may easily arise whereby flammable concentrations of ethanol vapor become trapped under the drapes and remain there for considerable periods. Recently the drapes on a patient undergoing thoracotomy in our institution caught fire. This prompted us to examine the problem closely. We placed a volunteer in the right lateral position over a chest support, as for a thoracotomy. The skin was prepared using weak iodine solution BP (iodine, 1.23%; potassium iodide, 1.23%; ethanol, 88.9%). Then, the area was draped using a Johnson & Johnson Surgikos disposable paper barrier thoracic drape, followed by an adherent Steri-Drape applied after the skin was dry. A suction probe was immediately placed under the drape, and the ethanol concentration was measured using a mass spectrometer (Centronics 200 MGA medical gas analyzer) connected to a Rikadenki 3 pen recorder. The spectrometer was calibrated using a flask saturated with ethanol vapor at a known temperature [3]. With the probe beside the volunteer’s back, the maximum level of ethanol vapor recorded was 1.8% volivol (minimum flammable level, 3.28%vol/vol 131). When the probe was placed anteriorly above the chest support, the level rose to 3.2% voli vol and then declined to less than 2.3%vol/vol after 40 seconds. In a repeat experiment in which a folded towel was placed between the chest and the support and the iodine solution was allowed to soak into the towel, vapor concentration remained above the minimum flammable level for more than four minutes. In preparation of a curved skin surface, as for a thoracotomy, skin preparation solution can easily run down the front and back of the patient. If this solution soaks into any absorbent material, a fire risk exists for several minutes. This would be exacerbated by use of a type of drape that is relatively impervious to ethanol vapor and thereby retards vapor dispersal. Also,