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Cardiac and Vascular Videos
0800–1030 Room: Miramar 3–4
Thursday, September 13, 2001 PII: S0967-2109(01)00078-3
Session XVIII Cardiac and Vascular Videos Co-Chairmen: Akira Furuse, Japan; Adib Jatena, Brazil 18.1 Evaluation of a New Sutureless Anastomotic Device in Coronary Surgery C. ANTONA, M. LEMMA. A. MANGINI, P. VANELLI, R. SCROFANI, C. CARRO and G. GELPI, Milan, Italy Background: For the last 10 years many varieties of suturing instruments for different branches of surgery have been designed. The purpose of this study was to have a preliminary assessment of the safety and efficacy of an automated device deigned to create the proximal anastomses of an aortic autologous vein graft. Methods: The device (St. Jude Medical Inc.Aortic Connector System) for performing a connection between the ascending aorta and the vein graft in coronary artery bypass surgery includes: (a) aortic connector (pre-loaded onto the release tubes), (b) handle, (c) nosecone, (d) aortic cutter, (e) vein transfer sheath (f) vein punch. The system is applicable in a conventional coronary surgery or in “off-pump” surgery. The proximal anastomoses is performed before because of the necessity to slide the vein over the vein transfer sheath; more than one graft can be connected in ascending aorta in the same patient avoiding any manipulation of the aorta. Results: Time for the management of all the aortic connection components and for vein loading procedure ranged from 4 to 8 minutes. Any leaks were noted in all the anastomoses performed. Neither acute myocardial infarction non neurologic events occurs in the postoperative period. Evaluation of anastomotic patency was carried out by angiography as soon as clinical condition permit the procedure: all the grafts studied were patent and no signs of neointimal hyperplasia were detected. All the patients were discharged from the hospital in antiplatelet therapy. Conclusion: Our preliminary results indicate that the St. Jude Aortic Connector System is safe and effective. It allows anastomoses approximately a 90° with aorta; we believe that for its more versatile the next development will provide the possibility to perform connection not only with this angle. Avoiding manipulation of aorta will reduce the risk of embolization from side clamping and aortic damage. The future lies in procedures that combine current sutures with technical instruments for an easier, quicker, less damaging, but reliable method to create a vascular anastomoses. More investigation and a long term follow-up in a largest group of patients are mandatory to confirm the data; if confirmed this preliminary report could suggest a new strategies in creating a suturless proximal anastomoses technique in coronary surgery.
18.2 Large Right Sinus of Valsalva Aneurysm and Aortic Valve Incompetence: Surgical Correction Using the Aortic Valve Sparing Operation C. ANTONA, M. LEMMA, A. MANGINI, P. VANELLI, G. GELPI, M. MUNARI and M. BOTTA, Milan, Italy A 61 years old patient underwent surgical repair of a large right sinus of Valsalva aneurysm, associated with mild aortic incompetence and coronary artery disease, using the valve sparing aortic root replacement. The patient had no symptoms and his illness was incidentally found during an angiography performed for the presence of unstable angina, that showed a critical lesion on the proximal part of the left anterior descending coronary artery. A subsequent MNR showed a large (4.7×5.0 cm) sinus of Valsalva aneurysm originating in the right coronary sinus. A TE echocardiography confirmed the diagnosis and demonstrated the presence of a mild aortic valve regurgitation due to asymmetric dilatation of the sinotubular junction. At surgery was found a large aneurysm of the right sinus of Valsalva associated with dilatation of the non coronary sinus. The right and non coronary sinus were reconstructed, the aortic valve was preserved and the geometry and the dimension of the sinotubular junction normalized using a 30 mm tubular Dacron graft. The right coronary was reimplanted on the new right coronary sinus and the left internal thoracic artery was used as an “in situ” graft on the left anterior coronary artery. The patient was weaned without any problem off cardioplumonary bypass and discharged from the hospital after 7 days from the operation. Postoperative echocardiography showed a normally patent aortic valve.
18.3 The Continuity of the Anterior Spinal Artery: Anatomical Basis and Surgical Technique to Prevent Paraplegia P. BIGLIOLI, M. ROBERTO, F. GRILLO, A. CANNATA and R. SPIRITO, Milan, Italy The paraplegia remains the most devastating complication of the descending thoracic aortic aneurysm repair. For this reason we decided to study the anatomy of the spinal cord blood supply. We investigated the anterior spinal artery (ASA) continuity and possible variation of the arteria radicularis magna of Adamkievicz (ARM) in 51 adult cadavers.
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25th World Congress of the ISCVS Methods: A dye injected through the vertebral artery of human cadavers colours the anterior spinal artery and the radicularis arteries in all 50 cases. Result: There is anatomic continuity among vertebral arteries, ASA and ARM. Consideration: On the basis of our anatomic findings, the sacrifice of the segmental arteries emerging from the aorta could be justified, and we suggest to perform the quick simple clamping technique to prevent spinal cord ischemic injury. From 1995 to October 2000 101 patients had descending thoracic aortic aneurysm repair, with a mortality of 1.9% (2/101) and neurologic complications (paraplegia) of 0.9% (1/101), maintaining the aortic cross-clamping time below 20 minutes. We think that the variable most closely related to reversible or irreversible spinal cord injury is the duration of the aortic cross-clamping time, and the spinal cord perfusion can be maintained adequately without reimplantation of segmental vessels or use of atriodistal bypass when the aortic cross-clamp time is short (<15 to 20 minutes).
18.5 Pulmonary Autograft (The Ross) Operation and "Pericardial Collar" Technique for the Right Ventricular Outflow Tract Reconstruction T. SARIOGLU, E. EREK, B. KINOGLU, E. SALIHOGLU, A. SARIOGLU and S. TEKIN, Istanbul, Turkey
18.4 Monitorization of Placental and Fetal Perfusion, During Surgical Management of Aortic Coarctation in a Pregnant Woman (Case Report) B. KINOGLU, E. SALIHOGLU, E. EREK, C. YILANLIOGLU, A. SARIOGLU, N. SOYBIR and T. SARIOGLU, Istanbul, Turkey Background: Coarctation of aorta is an unusual cause of hypertension in pregnancy. It is poorly tolerated during pregnancy and may cause maternal and fetal mortality. There is limited data regarding the outcome of pregnancy in patients with aortic coarction. Case: A 19-year-old woman presented at 16th gestation week with the complaint of headache. At physical examination, heart rate was 80/min. and blood pressure was 170/100 mmHg. Systolic ejection murmur was detected at left sternal border. Femoral pulses were absent. Left ventricular hypertrophy was present at ECG and echocardiographic examination was revealed severe aortic coarctation distal to left subclavian artery (65 mmHg gradient) and bicuspid aortic valve. No fetal pathologic finding was detected at amniotic fluid examination and fetal echocardiography. Because of known fetal and maternal risks of the condition, surgical therapy was planned and consent of the patient and her family was taken. Resection of coarctation and graft interposition by using 18 no. dacron tube graft was performed via left posterolateral thoracotomy under general anesthesia. Topical hypothermia (33°C) was employed during cross clamp period. Throughout the operation, radial and femoral artery pressures, and fetal heart rate were monitored continuously. Splanchnic perfusion was measured by using gastric tonometry catheter. Continuous doppler ultrasonography (Toshiba SSA 270A, 5 mhz, convex abdominal probe) was used to detect plasental and fetal perfusion during the operation. Pulsatility index (PI) of maternal uterin artery, PI of umbilical artery and PI of fetal median cerebral artery was measured to assess fetal and maternal perfusion. Transient decrease was detected in fetal heart rate from 138/min to 80/min during cross clamp and local hypothermia. Femoral artery pressure decreased to as low as 32 mmHg. But no other parameter was adversely affected from the operation. The patient had uneventful postoperative course with normal fetal findings at control USG examinations. At term, the patient had a healthy baby via vaginal delivery. Conclusion: In this case, fetomaternal circulation was not adversely affected during correction of aortic coarctation. We think that surgical management is appropriate for pregnant patients with severe coarctation of the aorta with acceptable maternal and fetal risk.
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Objectives: Technical demands of the Ross operation and two valves at risk have delayed acceptance. The results of 18 patients who underwent Ross procedure and a new pericardial collar technique for the reconstruction of RVOT was documented. Methods: Patients ages ranged from 9 to 37 years (mean 16.2⫾7.1 years). Three of them had prior open heart operation. Total root replacement technique was used in all patients Ross/Konno procedure was performed in 3 patients with subaortic stenosis and/or aortic root hypoplasia. We used homografts in 6 patients and stentless bioprosthesis in 12 patients for RVOT reconstructions. A new "pericardial collar technique" was used as part of RVOT reconstruction to avoid damage to the first septal artery during implantation and to prevent persistent bleeding from septal dissection area. A strip of pericardium was sutured to the epicardial edge of the posterior and septal part of the RVOT. Then conduit was sutured to the pericardial strip at the posterior part of the anastomosis. At the anterior part, conduit was sutured to the RV muscle. Results: One patient who operated urgently because of acute hemodynamic deterioration and active bacterial endocarditis died in early postoperative period. Right ventricular dysfunction and complete atrioventricular block was seen in a patient. Right mammary to right coronary artery bypass and permanent pacemaker implantation one month later was performed. One patient was reoperated owing to endocarditis. Other patients had uneventful postoperative course. Follow-up ranged from 1 to 32 months (mean 15.2⫾9) for all patients. Echocardiographic examinations during follow-up period showed normal aortic value or trivial aortic regurgitation in all but one patients, who had moderate aortic regurgitation. Conclusions: We can say that, Ross operation could be the alternative procedure for the prosthetic aortic valve replacement in selected patients (child, young adults and ladies) and we think that pericardial collar technique is a useful modification for Ross procedure.
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18.6
18.8
Thermal Angiographic Detection of Unexpected Flow Restricting Lesions B. SONMEZ, S. TANSAL, M. UNAL, N. YAGAN, H. ARBATLI and E. DEMIRSOY, Istanbul, Turkey
Total Replacement of the Thoracic Aorta by Modified Elephant Trunk Technique P.P. ZANETTI and P. LODDO, Cagliari, Italy
Background: Per operative coronary angiography has always been desired by coronary surgeons. Thermal camera detects heat differences between tissues and provides easy to interpret angiographic images and even calculates quantitative flow of grafts. Methods: Starting on January 2000 we used a thermal camera (OPGAL IVA 2000) on scheduled CABG operations. Upon completion of each distal anastomosis the perfusion of distal arterial tree from the graft is verified. Technical faults on the anastomosis or unexpected distal occluding plaques or any kind of flow restricting lesions can be detected immediately by this method and can be corrected during CPB. Results: This technique applied to 1000 patients with great success in 978 (98%). Twelve patients with excessive fat surrounding the heart and ten patients with very deep intramyocardial arteries could not be visualized enough. These 978 patients received 3080 distal anastomosis. Twenty-nine unsuccessful anastomosis with low or no flow due to technical errors [13/3080 (0.42%)] or flow restricting native arterial disease [16/3080) (0.52%)] were detected and corrected during the operation. In this group of patients 4 had periooperative MI (0.4%) and hospital mortality due to various reasons (0–30 days) was 15 (1.5%). Conclusion: Thermal camera easily detects the perfusion area and flow of the implanted graft. In the case of an insufficient result, it can be corrected during the same operation. We believe that the thermal camera will be the quality control device for coronary artery bypass operations.
18.7 Sutureless Repair of Free-Wall Left Ventricle Rupture Using BioGlue Surgical Adhesive P. TOTARO, G. COLETTI, R. LORUSSO, V. BORGHETTI, M. RAMBALDINI, E. TULUMELLO and G. MINZIONI, Brescia, Italy (Video)Cardiac free-wall rupture is a frequent and particularly dangerous condition following acute myocardial infarction. Due to the fact that most of the time the diagnosis is made with the patient in cardiogenic shock and/or cardiac tamponede a prompt surgical intervention is life-threatening. Several surgical procedures have been described depending on the type of cardiac rupture. In case of fissuration of the free-wall the simple repair by means of glued pericardial patch with or without reinforcing mattress suture is the technique of choice. The BioGlue Surgical Adhesive (Cryolife International Inc) is a new type of glue composed of bovine serum albumin cross-linked by glutaraldehyde, which has been extensively shown to be effective in acute type A dissection. In this video we present a case of fissuration-type cardiac rupture in which the BioGlue was successfully utilized to achieve an uneventful sutureless repair.
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The Borst’s technique allows the total replacement of the thoracic aorta in two different stages. First he replaced the ascending aorta and aortic arch by the well-known –elephant trunk technique" under hypothermic circulatory arrest, with a graft segment left in the descending aorta. Subsequently he completed the aortic aneurysm’s replacement using the graft segment by left thoracotomy. In our modified technique first we have replaced the thoracic segment of aorta using a folding graft by thoracotomy and Bio-pump, subsequently we have caught the fold segment of the graft to applying epiaortic vessels with a Carrel patch and replacing the ascending aorta. The goal of this "modified technique" is to reduce the time of circulatory arrest and to avoid one more handle sutures of the epiaortic vessels. Introduction: The aim of this work is to present our modified Elephant Trunk technique to reduce circulatory arrest time, and consequently mortality and morbidity rates. Materials and methods: According to the Borst’s technique, the ascending aorta and aortic arch are replaced first, under deep hypothermic circulatory arrest, while a graft segment is left in the descending thoracic aorta. In the second stage of the operation, the descending thoracic aorta is replaced through left thoracotomy using this graft segment. In our modified technique, after the flexion in the proximal segment of the graft, the descending thoracic aorta is replaced first through left thoracotomy and with Bio-pump protection, choosing the best aortic segment for proximal anastomosis. (Fig. n.1). In the second stage we replace the ascending aorta and the aortic arch using the graft segment (elephant trunk) reversed outside the first graft and applying Carrel patch anastomosis only to the epiaortic vessels, under deep hypothermic circulation arrest (Fig. n. 2–3–4). Our modified technique was performed on five patients out of 305 cases of thoracic aorta disease from 1994 to 1999. Results: The number of cases treated with our modified technique is too small for any significant comparison of mortality results. Nevertheless, it is our opinion that the mortality incidence of this technique is similar to that obtained with the Borst’s elephant trunk technique and with the "one-stage procedure". Infact there are fewer stroke incidents thanks to the reduced times of deep hypothermic circulatory arrest, and fewer postoperative bleedings and respiratory failures thanks to the reduced times of total cardiopulmonary bypass. Conclusions: At the beginning we used this technique to replace symptomatic aneurysms, covered ruptures, and hematomas of the wall of the descending thoracic aorta, which required replacement of the descending thoracic aorta first; we later extended the treatment to all types of thoracic aorta aneurysms. Our modified technique allows: (a) to perform proximal anastomosis in any site of the descending thoracic aorta with a Bio-pump, through left thoracotomy; (b) to avoid performing two sutures on the descending thoracic aorta and epiaortic vessels, which are often very close and difficult in the Borst’s technique, through sternotomy; (c) to reduce circulatory arrest time from 30–40 minutes to 12–18 minutes.
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25th World Congress of the ISCVS
18.9 Endovascular Treatment of Congenital Arterio-Venous Fistulas F. FLOTA, Merida, Yuc, Mexico The indication for surgical therapy and the technical aspects of all modern procedures are designed to eradicate the leak and possible to restore the circulatory pattern. Often bad results are obtained in the open surgical techniques caused by the high flow. The objective of this work is to show our experience in the treatment of this pathology with endovascular procedures in three patients. Materials and Methods: With a C arm arch by fluorescent endoscopic control using digital angiogram previous and during procedure to localize the anatomic site of arterio-venous (AV) fistula, the procedure was divided in three phases: (a) injection 10cc of aetoxiesclerol in the fistula site; (b) embolization with granulated polyvinyl alcohol and (c) installation of coils in the fistula tank. Results: In every case we obtain the complete occlusion of the AV fistulas and the restoration of normal circulatory pattern, following one year. Discussion: With the modern technology specially the angioscopy and the fixation of the AV fistula trunk we obtain a visualization of the progressive normalization in the arterial flow making easier the final phases of treatment. This visualization step by step improves the image of the arterial anatomy during the occlusion of each trunk, in that way we could observe that the complexity of this plexiform structures are lower and perhaps don’t exist a relation between high flow, number of fistulas and area of shunts.
18.10 Early Experience of Balloon Angioplasty in Alexandria University Hospitals R. NAGA, Alexandria, Egypt The video presentation shows the early experience of peripheral angioplasty in a rapidly growing new catheter lab at Alexandria University Hospital, Egypt. The type of arterial pathology in the middle-east patient has a special pattern. Yet, patterns in this country need some efforts to explain them in the procedure. The follow-up period in this series is short of statistical study, but the outcome is promising. I present 36 lower limbs with advanced lower limb ischaemia, in most of them surgical reconstruction do not appear to be safe. 60% of the procedures were angioplasty for the popliteal or infrapopliteal segment. Complications were nearly absent. Early outcome is very promising.
18.11 Less Invasive Aorto-Bifemoral Bypass Procedure Under Assisted Laparoscopy Y. INOUE, N. KURIHARA, T. IWASAKI, T. KUDO, N. NAKAMURA, M. HIROKAWA, N. SUGANO, H. INOUE and T. IWAI, Tokyo, Japan Postoperative activity was deteriorated due to operation even if postoperative course was uneventful especially in elderly and highrisk patients. Therefore, less invasive surgery was introduced for patients with aortoiliac occlusive disease. Patients were 9 male and
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2 female with a mean age of 64.7 years. The skin was incised 7 cm parallel to the left abdominal rectal muscle. The abdominal aorta was exposed just below the renal arteries through retroperitoneal approach using combined small incision at the left lower quadrant abdomen. After general heparinization, a bifurcated graft was anastomosed to the longitudinal aortotomy under assisted laparoscopy with trocar system. The graft limbs were anastomosed to the common femoral arteries in end-to-side fashion. Mean operative time was 281 minutes and mean intraoperative hemorrhage was 763 ml. All patients except one patient could start oral intake on the seocond or third postoperative day. This less invasive aorto-bifemoral bypass was a useful surgical procedure especially for patients which high risk, or might be acceptable to routine procedures.
18.12 Full Root Replacement for Re-Dissection of the Aortic Root T. KAZUI, K. YAMASHITA, A.H.M. BASHAR and N. WASHIYAMA, Hamamatsu, Shizuoka, Japan Background: Re-dissection of the aortic root after supracoronary aortic graft replacement with obliteration of the proximal false lumen is relatively rate. Methods: Four (3%) out of the 130 patients who were operated on for acute type A aortic dissection developed re-dissection of the aortic root associated with moderate to severe aortic regurgitation in the late postoperative period. In all patients, the proximal false lumen was obliterated with 4–0 monofilament running suture reinforced with Teflon felt strip placed on the outside of the aorta after infusing GRF glue or Bioglue into the false lumen. Two of these four cases are presented: Case 1: A 62 year-old female who underwent concomitant total arch replacement (TAR) for acute type A aortic dissection later required the full root replacement using free-style heterograft bioprosthesis (Medtronic) 13 months after the first operation. Case 2: A 57 year old male who underwent concomitant TAR for acute type A aortic dissection later required the full root replacement using composite graft prosthesis 27 months after the first operation. Results: All patients had uneventful postoperative course, and postoperative DSA showed satisfactory reconstruction of the aortic root.
18.13 Replacement of Aortic Arch with Arch-First Technique Through Median Sternotomy M. NISHIMURA, S. OHTAKE, Y. SAWA, O. MONTA and H. MATSUDA, Osaka, Japan Cerebral damage associated with repair of the aortic arch is a disastrous complication that may not only lead to operative death, but always worsens a patient’s quality of life. To reduce the rate of cerebral complication in aortic arch surgery, we started a new technique, "Arch-first technique". In this technique, arch vessels are transected during hypothermic circulatory arrest and reconstructed with branched prosthetic graft. Then, brain perfusion can be restarted through right axillary artery by placing clamps on both ends of the graft. By this way, we can restart antegrade cerebral perfusion after relatively short circulatory arrest while keeping the neck vessels untouched. Usually, the circulatory arrest time is less than 30 min
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25th World Congress of the ISCVS by this technique. Although our experience is still limited, the arch first technique may have a role in reducing cerebral complication during aortic arch surgery, especially in cases with severe atherosclerotic arch vessels.
18.14 Novel Anastomotic Technique of AortoFemoral Bypass For Patients with Porcelain Aorta T. SASAJIMA, K. GOH, M. INABA, N. AZUMA, H. ASADA, Y. SASAJIMA, H. UCHIDA and A. KOYA, Asahikawa, Hokkaido, Japan Porcelain aorta is an acceptable reason for employing axillofemoral byass; nevertheless, aorto-femoral bypass is preferable if possible. In this paper, we present a safe and reliable anastomotic technique for porcelain aorta and medium sized arteries. Technique: Porcelain aorta occasionally has a crevice, in which an aortic cross clamp is applied. When an adequate crevice is unpalpable, the aorta is occluded by an aortic occlusion balloon. The anastomotic site of the aorta is first wrapped with teflon mesh (#0117841, Bard). The adventia at the anastomosis is cut over the mesh, and the cut margins of the mesh and the adventitia are fixed with continuous sutures of 4–0 polyproplylene. The calcification is penetrated by an air-drill, and the hole is then enlarged by a laminectomy rongeur into an adequate anastomotic size, which is above five mm greater than the size of the fixed adventitial margin. The anastomosis is performed with the mesh reinforced adventitia. The distal anastomosis with the femoral artery is performed in the same manner. Patients: Since April 1996, this technique has been applied to 7 patients with porcelain aorta and/or arteries. These included 3 with chronic hemodialysis and 4 with atherosclerosis. The indication for surgery were 3 disabling claudication and 4 limb salvage. The pro-
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cedures included 4 aorto-femoral (-femoral) bypasses, 2 aortofemoro-femoral-crural bypasses, and one femoro-femoro-crural bypass. Results: There were no anastomotic complications, and satisfactory early and long-term results were obtained in all of the patients. Of 7 patients, 3 died of coronary heart disease or cancer, but all of the grafts were patent. Conclusion: The present results justified more liberal application of this technique, especially in younger patients with porcelain aorta.
18.15 Complete Revascularization Including Posterior Coronary Arteries with OPCAB (Median Sternotomy, Off-Pump CABG) T. TASHIRO, K. NAKAMURA, Y. TACHIKAWA, R. SHIBANO, R. ZAITU, H. IWAHASHI, A. MURAI and M. KIMURA, Fukuoka, Japan Advance of surgical technique (Lima suture) and mechanical stabilizer (Octopus II) allowed the surgeon to revasculize posterior coronary arteries without pump. From February 1999, through September 2000, 117 patients underwent OPCAB. They were 62% of isolates CABG during same period. Indication of OPCAB was patients who have comorbid condition (CVD, renal failure, calcified ascending aorta or elderly). Mean age was 68.5 years old in OPCAB group. Mean number of diseased vessels were 2.4. Mean number of anastomoses per patient was 2.6 (range 1–5). In 86 patients (74%), posterior coronary arteries were revascularized. The postoperative complication rate and medical cost was low compared to on-pump group. There was one (1%) in-hospital death. The graft patency rate were 96%. OPCAB was safe, cost effective, and associated with excellent graft patency and clinical outcomes. We will present our operative technique with video.
CARDIOVASCULAR SURGERY
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Thursday, September 13, 2001 PII: S0967-2109(01)00078-3
Session XVIII Cardiac and Vascular Videos Co-Chairmen: Akira Furuse, Japan; Adib Jatena, Brazil 18.1 Evaluation of a New Sutureless Anastomotic Device in Coronary Surgery C. ANTONA, M. LEMMA. A. MANGINI, P. VANELLI, R. SCROFANI, C. CARRO and G. GELPI, Milan, Italy Background: For the last 10 years many varieties of suturing instruments for different branches of surgery have been designed. The purpose of this study was to have a preliminary assessment of the safety and efficacy of an automated device deigned to create the proximal anastomses of an aortic autologous vein graft. Methods: The device (St. Jude Medical Inc.Aortic Connector System) for performing a connection between the ascending aorta and the vein graft in coronary artery bypass surgery includes: (a) aortic connector (pre-loaded onto the release tubes), (b) handle, (c) nosecone, (d) aortic cutter, (e) vein transfer sheath (f) vein punch. The system is applicable in a conventional coronary surgery or in “off-pump” surgery. The proximal anastomoses is performed before because of the necessity to slide the vein over the vein transfer sheath; more than one graft can be connected in ascending aorta in the same patient avoiding any manipulation of the aorta. Results: Time for the management of all the aortic connection components and for vein loading procedure ranged from 4 to 8 minutes. Any leaks were noted in all the anastomoses performed. Neither acute myocardial infarction non neurologic events occurs in the postoperative period. Evaluation of anastomotic patency was carried out by angiography as soon as clinical condition permit the procedure: all the grafts studied were patent and no signs of neointimal hyperplasia were detected. All the patients were discharged from the hospital in antiplatelet therapy. Conclusion: Our preliminary results indicate that the St. Jude Aortic Connector System is safe and effective. It allows anastomoses approximately a 90° with aorta; we believe that for its more versatile the next development will provide the possibility to perform connection not only with this angle. Avoiding manipulation of aorta will reduce the risk of embolization from side clamping and aortic damage. The future lies in procedures that combine current sutures with technical instruments for an easier, quicker, less damaging, but reliable method to create a vascular anastomoses. More investigation and a long term follow-up in a largest group of patients are mandatory to confirm the data; if confirmed this preliminary report could suggest a new strategies in creating a suturless proximal anastomoses technique in coronary surgery.
18.2 Large Right Sinus of Valsalva Aneurysm and Aortic Valve Incompetence: Surgical Correction Using the Aortic Valve Sparing Operation C. ANTONA, M. LEMMA, A. MANGINI, P. VANELLI, G. GELPI, M. MUNARI and M. BOTTA, Milan, Italy A 61 years old patient underwent surgical repair of a large right sinus of Valsalva aneurysm, associated with mild aortic incompetence and coronary artery disease, using the valve sparing aortic root replacement. The patient had no symptoms and his illness was incidentally found during an angiography performed for the presence of unstable angina, that showed a critical lesion on the proximal part of the left anterior descending coronary artery. A subsequent MNR showed a large (4.7×5.0 cm) sinus of Valsalva aneurysm originating in the right coronary sinus. A TE echocardiography confirmed the diagnosis and demonstrated the presence of a mild aortic valve regurgitation due to asymmetric dilatation of the sinotubular junction. At surgery was found a large aneurysm of the right sinus of Valsalva associated with dilatation of the non coronary sinus. The right and non coronary sinus were reconstructed, the aortic valve was preserved and the geometry and the dimension of the sinotubular junction normalized using a 30 mm tubular Dacron graft. The right coronary was reimplanted on the new right coronary sinus and the left internal thoracic artery was used as an “in situ” graft on the left anterior coronary artery. The patient was weaned without any problem off cardioplumonary bypass and discharged from the hospital after 7 days from the operation. Postoperative echocardiography showed a normally patent aortic valve.
18.3 The Continuity of the Anterior Spinal Artery: Anatomical Basis and Surgical Technique to Prevent Paraplegia P. BIGLIOLI, M. ROBERTO, F. GRILLO, A. CANNATA and R. SPIRITO, Milan, Italy The paraplegia remains the most devastating complication of the descending thoracic aortic aneurysm repair. For this reason we decided to study the anatomy of the spinal cord blood supply. We investigated the anterior spinal artery (ASA) continuity and possible variation of the arteria radicularis magna of Adamkievicz (ARM) in 51 adult cadavers.
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25th World Congress of the ISCVS Methods: A dye injected through the vertebral artery of human cadavers colours the anterior spinal artery and the radicularis arteries in all 50 cases. Result: There is anatomic continuity among vertebral arteries, ASA and ARM. Consideration: On the basis of our anatomic findings, the sacrifice of the segmental arteries emerging from the aorta could be justified, and we suggest to perform the quick simple clamping technique to prevent spinal cord ischemic injury. From 1995 to October 2000 101 patients had descending thoracic aortic aneurysm repair, with a mortality of 1.9% (2/101) and neurologic complications (paraplegia) of 0.9% (1/101), maintaining the aortic cross-clamping time below 20 minutes. We think that the variable most closely related to reversible or irreversible spinal cord injury is the duration of the aortic cross-clamping time, and the spinal cord perfusion can be maintained adequately without reimplantation of segmental vessels or use of atriodistal bypass when the aortic cross-clamp time is short (<15 to 20 minutes).
18.5 Pulmonary Autograft (The Ross) Operation and "Pericardial Collar" Technique for the Right Ventricular Outflow Tract Reconstruction T. SARIOGLU, E. EREK, B. KINOGLU, E. SALIHOGLU, A. SARIOGLU and S. TEKIN, Istanbul, Turkey
18.4 Monitorization of Placental and Fetal Perfusion, During Surgical Management of Aortic Coarctation in a Pregnant Woman (Case Report) B. KINOGLU, E. SALIHOGLU, E. EREK, C. YILANLIOGLU, A. SARIOGLU, N. SOYBIR and T. SARIOGLU, Istanbul, Turkey Background: Coarctation of aorta is an unusual cause of hypertension in pregnancy. It is poorly tolerated during pregnancy and may cause maternal and fetal mortality. There is limited data regarding the outcome of pregnancy in patients with aortic coarction. Case: A 19-year-old woman presented at 16th gestation week with the complaint of headache. At physical examination, heart rate was 80/min. and blood pressure was 170/100 mmHg. Systolic ejection murmur was detected at left sternal border. Femoral pulses were absent. Left ventricular hypertrophy was present at ECG and echocardiographic examination was revealed severe aortic coarctation distal to left subclavian artery (65 mmHg gradient) and bicuspid aortic valve. No fetal pathologic finding was detected at amniotic fluid examination and fetal echocardiography. Because of known fetal and maternal risks of the condition, surgical therapy was planned and consent of the patient and her family was taken. Resection of coarctation and graft interposition by using 18 no. dacron tube graft was performed via left posterolateral thoracotomy under general anesthesia. Topical hypothermia (33°C) was employed during cross clamp period. Throughout the operation, radial and femoral artery pressures, and fetal heart rate were monitored continuously. Splanchnic perfusion was measured by using gastric tonometry catheter. Continuous doppler ultrasonography (Toshiba SSA 270A, 5 mhz, convex abdominal probe) was used to detect plasental and fetal perfusion during the operation. Pulsatility index (PI) of maternal uterin artery, PI of umbilical artery and PI of fetal median cerebral artery was measured to assess fetal and maternal perfusion. Transient decrease was detected in fetal heart rate from 138/min to 80/min during cross clamp and local hypothermia. Femoral artery pressure decreased to as low as 32 mmHg. But no other parameter was adversely affected from the operation. The patient had uneventful postoperative course with normal fetal findings at control USG examinations. At term, the patient had a healthy baby via vaginal delivery. Conclusion: In this case, fetomaternal circulation was not adversely affected during correction of aortic coarctation. We think that surgical management is appropriate for pregnant patients with severe coarctation of the aorta with acceptable maternal and fetal risk.
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Objectives: Technical demands of the Ross operation and two valves at risk have delayed acceptance. The results of 18 patients who underwent Ross procedure and a new pericardial collar technique for the reconstruction of RVOT was documented. Methods: Patients ages ranged from 9 to 37 years (mean 16.2⫾7.1 years). Three of them had prior open heart operation. Total root replacement technique was used in all patients Ross/Konno procedure was performed in 3 patients with subaortic stenosis and/or aortic root hypoplasia. We used homografts in 6 patients and stentless bioprosthesis in 12 patients for RVOT reconstructions. A new "pericardial collar technique" was used as part of RVOT reconstruction to avoid damage to the first septal artery during implantation and to prevent persistent bleeding from septal dissection area. A strip of pericardium was sutured to the epicardial edge of the posterior and septal part of the RVOT. Then conduit was sutured to the pericardial strip at the posterior part of the anastomosis. At the anterior part, conduit was sutured to the RV muscle. Results: One patient who operated urgently because of acute hemodynamic deterioration and active bacterial endocarditis died in early postoperative period. Right ventricular dysfunction and complete atrioventricular block was seen in a patient. Right mammary to right coronary artery bypass and permanent pacemaker implantation one month later was performed. One patient was reoperated owing to endocarditis. Other patients had uneventful postoperative course. Follow-up ranged from 1 to 32 months (mean 15.2⫾9) for all patients. Echocardiographic examinations during follow-up period showed normal aortic value or trivial aortic regurgitation in all but one patients, who had moderate aortic regurgitation. Conclusions: We can say that, Ross operation could be the alternative procedure for the prosthetic aortic valve replacement in selected patients (child, young adults and ladies) and we think that pericardial collar technique is a useful modification for Ross procedure.
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25th World Congress of the ISCVS
18.6
18.8
Thermal Angiographic Detection of Unexpected Flow Restricting Lesions B. SONMEZ, S. TANSAL, M. UNAL, N. YAGAN, H. ARBATLI and E. DEMIRSOY, Istanbul, Turkey
Total Replacement of the Thoracic Aorta by Modified Elephant Trunk Technique P.P. ZANETTI and P. LODDO, Cagliari, Italy
Background: Per operative coronary angiography has always been desired by coronary surgeons. Thermal camera detects heat differences between tissues and provides easy to interpret angiographic images and even calculates quantitative flow of grafts. Methods: Starting on January 2000 we used a thermal camera (OPGAL IVA 2000) on scheduled CABG operations. Upon completion of each distal anastomosis the perfusion of distal arterial tree from the graft is verified. Technical faults on the anastomosis or unexpected distal occluding plaques or any kind of flow restricting lesions can be detected immediately by this method and can be corrected during CPB. Results: This technique applied to 1000 patients with great success in 978 (98%). Twelve patients with excessive fat surrounding the heart and ten patients with very deep intramyocardial arteries could not be visualized enough. These 978 patients received 3080 distal anastomosis. Twenty-nine unsuccessful anastomosis with low or no flow due to technical errors [13/3080 (0.42%)] or flow restricting native arterial disease [16/3080) (0.52%)] were detected and corrected during the operation. In this group of patients 4 had periooperative MI (0.4%) and hospital mortality due to various reasons (0–30 days) was 15 (1.5%). Conclusion: Thermal camera easily detects the perfusion area and flow of the implanted graft. In the case of an insufficient result, it can be corrected during the same operation. We believe that the thermal camera will be the quality control device for coronary artery bypass operations.
18.7 Sutureless Repair of Free-Wall Left Ventricle Rupture Using BioGlue Surgical Adhesive P. TOTARO, G. COLETTI, R. LORUSSO, V. BORGHETTI, M. RAMBALDINI, E. TULUMELLO and G. MINZIONI, Brescia, Italy (Video)Cardiac free-wall rupture is a frequent and particularly dangerous condition following acute myocardial infarction. Due to the fact that most of the time the diagnosis is made with the patient in cardiogenic shock and/or cardiac tamponede a prompt surgical intervention is life-threatening. Several surgical procedures have been described depending on the type of cardiac rupture. In case of fissuration of the free-wall the simple repair by means of glued pericardial patch with or without reinforcing mattress suture is the technique of choice. The BioGlue Surgical Adhesive (Cryolife International Inc) is a new type of glue composed of bovine serum albumin cross-linked by glutaraldehyde, which has been extensively shown to be effective in acute type A dissection. In this video we present a case of fissuration-type cardiac rupture in which the BioGlue was successfully utilized to achieve an uneventful sutureless repair.
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The Borst’s technique allows the total replacement of the thoracic aorta in two different stages. First he replaced the ascending aorta and aortic arch by the well-known –elephant trunk technique" under hypothermic circulatory arrest, with a graft segment left in the descending aorta. Subsequently he completed the aortic aneurysm’s replacement using the graft segment by left thoracotomy. In our modified technique first we have replaced the thoracic segment of aorta using a folding graft by thoracotomy and Bio-pump, subsequently we have caught the fold segment of the graft to applying epiaortic vessels with a Carrel patch and replacing the ascending aorta. The goal of this "modified technique" is to reduce the time of circulatory arrest and to avoid one more handle sutures of the epiaortic vessels. Introduction: The aim of this work is to present our modified Elephant Trunk technique to reduce circulatory arrest time, and consequently mortality and morbidity rates. Materials and methods: According to the Borst’s technique, the ascending aorta and aortic arch are replaced first, under deep hypothermic circulatory arrest, while a graft segment is left in the descending thoracic aorta. In the second stage of the operation, the descending thoracic aorta is replaced through left thoracotomy using this graft segment. In our modified technique, after the flexion in the proximal segment of the graft, the descending thoracic aorta is replaced first through left thoracotomy and with Bio-pump protection, choosing the best aortic segment for proximal anastomosis. (Fig. n.1). In the second stage we replace the ascending aorta and the aortic arch using the graft segment (elephant trunk) reversed outside the first graft and applying Carrel patch anastomosis only to the epiaortic vessels, under deep hypothermic circulation arrest (Fig. n. 2–3–4). Our modified technique was performed on five patients out of 305 cases of thoracic aorta disease from 1994 to 1999. Results: The number of cases treated with our modified technique is too small for any significant comparison of mortality results. Nevertheless, it is our opinion that the mortality incidence of this technique is similar to that obtained with the Borst’s elephant trunk technique and with the "one-stage procedure". Infact there are fewer stroke incidents thanks to the reduced times of deep hypothermic circulatory arrest, and fewer postoperative bleedings and respiratory failures thanks to the reduced times of total cardiopulmonary bypass. Conclusions: At the beginning we used this technique to replace symptomatic aneurysms, covered ruptures, and hematomas of the wall of the descending thoracic aorta, which required replacement of the descending thoracic aorta first; we later extended the treatment to all types of thoracic aorta aneurysms. Our modified technique allows: (a) to perform proximal anastomosis in any site of the descending thoracic aorta with a Bio-pump, through left thoracotomy; (b) to avoid performing two sutures on the descending thoracic aorta and epiaortic vessels, which are often very close and difficult in the Borst’s technique, through sternotomy; (c) to reduce circulatory arrest time from 30–40 minutes to 12–18 minutes.
CARDIOVASCULAR SURGERY
SEPTEMBER 2001
25th World Congress of the ISCVS
18.9 Endovascular Treatment of Congenital Arterio-Venous Fistulas F. FLOTA, Merida, Yuc, Mexico The indication for surgical therapy and the technical aspects of all modern procedures are designed to eradicate the leak and possible to restore the circulatory pattern. Often bad results are obtained in the open surgical techniques caused by the high flow. The objective of this work is to show our experience in the treatment of this pathology with endovascular procedures in three patients. Materials and Methods: With a C arm arch by fluorescent endoscopic control using digital angiogram previous and during procedure to localize the anatomic site of arterio-venous (AV) fistula, the procedure was divided in three phases: (a) injection 10cc of aetoxiesclerol in the fistula site; (b) embolization with granulated polyvinyl alcohol and (c) installation of coils in the fistula tank. Results: In every case we obtain the complete occlusion of the AV fistulas and the restoration of normal circulatory pattern, following one year. Discussion: With the modern technology specially the angioscopy and the fixation of the AV fistula trunk we obtain a visualization of the progressive normalization in the arterial flow making easier the final phases of treatment. This visualization step by step improves the image of the arterial anatomy during the occlusion of each trunk, in that way we could observe that the complexity of this plexiform structures are lower and perhaps don’t exist a relation between high flow, number of fistulas and area of shunts.
18.10 Early Experience of Balloon Angioplasty in Alexandria University Hospitals R. NAGA, Alexandria, Egypt The video presentation shows the early experience of peripheral angioplasty in a rapidly growing new catheter lab at Alexandria University Hospital, Egypt. The type of arterial pathology in the middle-east patient has a special pattern. Yet, patterns in this country need some efforts to explain them in the procedure. The follow-up period in this series is short of statistical study, but the outcome is promising. I present 36 lower limbs with advanced lower limb ischaemia, in most of them surgical reconstruction do not appear to be safe. 60% of the procedures were angioplasty for the popliteal or infrapopliteal segment. Complications were nearly absent. Early outcome is very promising.
18.11 Less Invasive Aorto-Bifemoral Bypass Procedure Under Assisted Laparoscopy Y. INOUE, N. KURIHARA, T. IWASAKI, T. KUDO, N. NAKAMURA, M. HIROKAWA, N. SUGANO, H. INOUE and T. IWAI, Tokyo, Japan Postoperative activity was deteriorated due to operation even if postoperative course was uneventful especially in elderly and highrisk patients. Therefore, less invasive surgery was introduced for patients with aortoiliac occlusive disease. Patients were 9 male and
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2 female with a mean age of 64.7 years. The skin was incised 7 cm parallel to the left abdominal rectal muscle. The abdominal aorta was exposed just below the renal arteries through retroperitoneal approach using combined small incision at the left lower quadrant abdomen. After general heparinization, a bifurcated graft was anastomosed to the longitudinal aortotomy under assisted laparoscopy with trocar system. The graft limbs were anastomosed to the common femoral arteries in end-to-side fashion. Mean operative time was 281 minutes and mean intraoperative hemorrhage was 763 ml. All patients except one patient could start oral intake on the seocond or third postoperative day. This less invasive aorto-bifemoral bypass was a useful surgical procedure especially for patients which high risk, or might be acceptable to routine procedures.
18.12 Full Root Replacement for Re-Dissection of the Aortic Root T. KAZUI, K. YAMASHITA, A.H.M. BASHAR and N. WASHIYAMA, Hamamatsu, Shizuoka, Japan Background: Re-dissection of the aortic root after supracoronary aortic graft replacement with obliteration of the proximal false lumen is relatively rate. Methods: Four (3%) out of the 130 patients who were operated on for acute type A aortic dissection developed re-dissection of the aortic root associated with moderate to severe aortic regurgitation in the late postoperative period. In all patients, the proximal false lumen was obliterated with 4–0 monofilament running suture reinforced with Teflon felt strip placed on the outside of the aorta after infusing GRF glue or Bioglue into the false lumen. Two of these four cases are presented: Case 1: A 62 year-old female who underwent concomitant total arch replacement (TAR) for acute type A aortic dissection later required the full root replacement using free-style heterograft bioprosthesis (Medtronic) 13 months after the first operation. Case 2: A 57 year old male who underwent concomitant TAR for acute type A aortic dissection later required the full root replacement using composite graft prosthesis 27 months after the first operation. Results: All patients had uneventful postoperative course, and postoperative DSA showed satisfactory reconstruction of the aortic root.
18.13 Replacement of Aortic Arch with Arch-First Technique Through Median Sternotomy M. NISHIMURA, S. OHTAKE, Y. SAWA, O. MONTA and H. MATSUDA, Osaka, Japan Cerebral damage associated with repair of the aortic arch is a disastrous complication that may not only lead to operative death, but always worsens a patient’s quality of life. To reduce the rate of cerebral complication in aortic arch surgery, we started a new technique, "Arch-first technique". In this technique, arch vessels are transected during hypothermic circulatory arrest and reconstructed with branched prosthetic graft. Then, brain perfusion can be restarted through right axillary artery by placing clamps on both ends of the graft. By this way, we can restart antegrade cerebral perfusion after relatively short circulatory arrest while keeping the neck vessels untouched. Usually, the circulatory arrest time is less than 30 min
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25th World Congress of the ISCVS by this technique. Although our experience is still limited, the arch first technique may have a role in reducing cerebral complication during aortic arch surgery, especially in cases with severe atherosclerotic arch vessels.
18.14 Novel Anastomotic Technique of AortoFemoral Bypass For Patients with Porcelain Aorta T. SASAJIMA, K. GOH, M. INABA, N. AZUMA, H. ASADA, Y. SASAJIMA, H. UCHIDA and A. KOYA, Asahikawa, Hokkaido, Japan Porcelain aorta is an acceptable reason for employing axillofemoral byass; nevertheless, aorto-femoral bypass is preferable if possible. In this paper, we present a safe and reliable anastomotic technique for porcelain aorta and medium sized arteries. Technique: Porcelain aorta occasionally has a crevice, in which an aortic cross clamp is applied. When an adequate crevice is unpalpable, the aorta is occluded by an aortic occlusion balloon. The anastomotic site of the aorta is first wrapped with teflon mesh (#0117841, Bard). The adventia at the anastomosis is cut over the mesh, and the cut margins of the mesh and the adventitia are fixed with continuous sutures of 4–0 polyproplylene. The calcification is penetrated by an air-drill, and the hole is then enlarged by a laminectomy rongeur into an adequate anastomotic size, which is above five mm greater than the size of the fixed adventitial margin. The anastomosis is performed with the mesh reinforced adventitia. The distal anastomosis with the femoral artery is performed in the same manner. Patients: Since April 1996, this technique has been applied to 7 patients with porcelain aorta and/or arteries. These included 3 with chronic hemodialysis and 4 with atherosclerosis. The indication for surgery were 3 disabling claudication and 4 limb salvage. The pro-
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cedures included 4 aorto-femoral (-femoral) bypasses, 2 aortofemoro-femoral-crural bypasses, and one femoro-femoro-crural bypass. Results: There were no anastomotic complications, and satisfactory early and long-term results were obtained in all of the patients. Of 7 patients, 3 died of coronary heart disease or cancer, but all of the grafts were patent. Conclusion: The present results justified more liberal application of this technique, especially in younger patients with porcelain aorta.
18.15 Complete Revascularization Including Posterior Coronary Arteries with OPCAB (Median Sternotomy, Off-Pump CABG) T. TASHIRO, K. NAKAMURA, Y. TACHIKAWA, R. SHIBANO, R. ZAITU, H. IWAHASHI, A. MURAI and M. KIMURA, Fukuoka, Japan Advance of surgical technique (Lima suture) and mechanical stabilizer (Octopus II) allowed the surgeon to revasculize posterior coronary arteries without pump. From February 1999, through September 2000, 117 patients underwent OPCAB. They were 62% of isolates CABG during same period. Indication of OPCAB was patients who have comorbid condition (CVD, renal failure, calcified ascending aorta or elderly). Mean age was 68.5 years old in OPCAB group. Mean number of diseased vessels were 2.4. Mean number of anastomoses per patient was 2.6 (range 1–5). In 86 patients (74%), posterior coronary arteries were revascularized. The postoperative complication rate and medical cost was low compared to on-pump group. There was one (1%) in-hospital death. The graft patency rate were 96%. OPCAB was safe, cost effective, and associated with excellent graft patency and clinical outcomes. We will present our operative technique with video.
CARDIOVASCULAR SURGERY
SEPTEMBER 2001