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Simplified technique for hemi-arch replacement during open distal anastomosis: The “calla” method
Simplified Technique for Hemi-Arch Replacement During Open Distal Anastomosis: The "Calla" Method Tohru Sakamoto, MD, PhD, Tetsuya Yoshida, MD, Takahiko Sugano, MD, Atsushi Kudoh, MD, and Akio Suzuki, MD, PhD Department of Cardiothoracic Surgery, School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
During open distal anastomosis for type A dissecting aneurysm, the beveled end of the graft was rolled back like a bract of the Calla flower and inserted into the aortic lumen. The inverted graft was anastomosed using forehand continuous sutures. After completion of the distal anastomosis, the inverted graft was pulled out and then
the proximal anastomosis was completed. This "Calla flower" deformation facilitates the hemostatic distal anastomosis in hemi-arch replacement during open distal anastomosis.
n the surgical treatment of thoracic aneurysm, various techniques have been used for aortic anastomosis. These include the inclusion technique I1], open distal anastomosis [2], elephant trunk [3], and invaginated distal anastomosis [4, 5]. Here we describe an anastomotic technique useful for treatment of type A dissecting aneurysm.
sutures directed the posterior edge of the inverted graft anteriorly with the opened posterior aortic wall, and a strip of Teflon felt was positioned outside the aorta for reinforcement (Fig 1). These posterior edges were easily sutured using a forehand suture with a bloodless field. The anterior edges were sutured using the same technique and the inverted graft was pulled out after completion of the distal anastomosis (Fig 2). Any air was removed from the arch vessels by retrograde cerebral perfusion while the patient remained in a head-down position, and hemostasis was secured by filling the graft with returned blood from the retrograde cerebral perfusion. The graft was then clamped and antegrade cerebral perfusion was resumed through the femoral artery cannula. During p u m p rewarming, the proximal anastomosis was completed and the patient was weaned uneventfully from cardiopulmonary bypass.
I
Technique
A 72-year-old w o m a n underwent hemi-arch replacement for type A dissecting aneurysm. A standard median sternotomy was performed and core cooling was instituted. With circulatory arrest at a core temperature of 19°C, the transverse aortic arch was incised longitudinally near the ligamentum arteriosum and then the cardiopulmonary bypass was slowly resumed through the femoral artery cannula with balloon occlusion of the descending aorta. The three-head vessels were inspected from inside the aortic arch and were found to be uninvolved, leading to the decision to use a hemi-arch graft replacement. The Hemashield woven graft (diameter, 30 ram) was beveled, adjusting the length of the oblique cut to the size of the transected aortic arch. Then the beveled end of the graft was widely rolled back and deformed like a bract of the Calla flower (a flower belonging to the arum family). This inverted graft was placed into the opened transverse aorta and retrograde cerebral perfusion was started. Two stay sutures were placed in the toe and heal of the anastomosis, and a flexible intracardiac suction catheter was inserted into the arch through the graft to aspirate the overflow from retrograde cerebral perfusion. Retraction of the stay Accepted for publication Sep 29, 1995. Address reprint requests to Dr Sakamoto, Department of Cardiothoracic Surgery, School of Medicine, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113, Japan.
© 1996 by The Society of Thoracic Surgeons Published by Elsevier Science lnc
(Ann Thorac Surg 1996;61:1021-3)
Comment
Open distal anastomosis has been widely accepted as a standard technique in operations for thoracic aneurysms. The inversion of the graft within itself ("invagination") was first reported by Griepp and colleagues [4] to anastomose the graft to the proximal descending aorta for arch replacement. Svensson [51 has modified this technique and emphasized that the suture line is automatically tightened after the graft is unfolded, resulting in freedom from bleeding. Hemostasis is not only achieved by the unfolding effect. In addition, the suture increases surface contact area between the graft and the aortic wall [5], and the graft is doubled over on itself with a reduced risk of bleeding at the aortic arch anastomotic site. In a patient with type A dissecting aneurysm, hemiarch replacement was planned, and the beveled end of the graft itself was widely rolled back like a bract of the Calla flower. The more oblique the beveled end of the graft, the larger the bract of the "Calla" becomes, and the 0003-4975/961515.00 SSDI 0003-4975(95)01140-4
1022
H O W TO DO 1T SAKAMOTO ET AL " C A L L A " METHOD FOR OPEN DISTAL ANASTOMOSIS
Ann Thorac Surg 1996;61:1021-3
S (A)
Fig 1. (A) Calla flower, belonging to the arum family. (B) Beveled end of the graft itself is rolled back like a bract of the Calla flower. (C) The inverted graft is placed into the aortic lumen and the anastomosis of the graft to the aorta is carried out with a single continuous suture sandwiching the aorta between the graft on the inside and the Teflon felt on the outside. Fig 2. Intraoperative view of hemi-arch replacement using the Calla method.
space b e t w e e n the suture line a n d the trunk of the graft becomes wider, facilitating a f o r e h a n d continuous suture. In 1969, Pearce a n d colleagues [6] r e p o r t e d a simplified technique to anastomose the three h e a d vessels as a cuff in operation for a n e u r y s m s of the aortic arch, b u t only if the distal aortic arch and the vessels were not involved. H e m i - a r c h r e p l a c e m e n t using the Calla graft technique w o u l d be possible as an alternative simplified method. In a patient with type B dissecting aneurysm, this technique has b e e n also a p p l i e d in total r e p l a c e m e n t of the descending aorta, leaving the Adamkiewicz vessel with a beveled distal thoracic aorta. We are grateful to Dr Juro Wada (Wada Heart and Lung Institute, Tokyo, Japan) and Dr James L. Cox (Division of Cardiothoracic Surgery, Washington University, St. Louis, MO) for their excellent comments in the preparation of this article.
References 1. Bentall H, De Bono A. A technique for complete replacement of the ascending aorta. Thorax 1968;23:338-9. 2. Cooley DA, Livesay JJ. Technique of "open" distal anastomosis for ascending and transverse arch resection. Cardiovasc Dis 1981;8:421-6. 3. Borst HG, Walterbush G, Schaps D. Extensive aortic replacement using "elephant trunk" prosthesis. Thorac Cardiovasc Surg 1983;31:37-40. 4. Griepp RB, Stinson EB, Hollingsworth JF, Buehler D. Prosthetic replacement of the aortic arch. J Thorac Cardiovasc Surg 1975;70:1051-63. 5. Svensson LG. Rationale and technique for replacement of the ascending aorta, arch, and distal aorta using a modified elephant trunk procedure. J Cardiac Surg 1992;7:301-12. 6. Pearce CW, Weichert RF III, del Real RE. Aneurysm of aortic arch. Simplified technique for excision and prosthetic replacement. J Thorac Cardiovasc Surg 1969;58:886-90.
INVITED COMMENTARY
Careful observation of nature has led m a n y a creative m i n d to innovation. In this regard, it is p r o b a b l y no coincidence that the African Calla lily flourishes near the water holes frequented b y e l e p h a n t trunks. The technical challenges of repairing the acutely dissected aorta include the r e a p p r o x i m a t i o n of the friable aortic layers. This is c o m m o n l y p e r f o r m e d by compressing the layers b e t w e e n parallel concentric strips of Teflon felt. In a second step, the r e p a i r e d aorta is a n a s t o m o s e d to a Dacron graft. This portion of the p r o c e d u r e is
typically p e r f o r m e d in an open m a n n e r u n d e r a period of profoundly h y p o t h e r m i c circulatory arrest. The Calla flower technique for aortic repair permits quick repair of the dissection and graft anastomosis in one step. The n e e d for the extra step of r e a p p r o x i m a t i n g the aortic layers with parallel concentric strips of Teflon felt is eliminated. This is because once the Dacron graft is inverted, it b e c o m e s the inner buttressing layer. W h e n the graft is ultimately pressurized, the o u t w a r d force of the blood with the l u m e n causes the aortic wall to be
Ann Thorac Surg 1996;61:1021-3
HOW TO DO IT SAKAMOTOET AL "CALLA" METHOD FOR OPEN DISTAL d~NASTOMOSIS
c o m p r e s s e d b e t w e e n t h e g r a f t a n d t h e o u t e r T e f l o n felt strip. In d o i n g this, h e m o s t a s i s is facilitated. Fortunately, after a personal communication, I had the o p p o r t u n i t y to t e s t t h i s s i m p l e m e t h o d . T h e C a l l a f l o w e r t e c h n i q u e is i n d e e d e x p e d i t i o u s a n d h e m o s t a t i c . T h e m e t h o d also l e n d s itself to t h e u s e of f i n e r s u t u r e m a t e rial, w h i c h m a y b e i m p o r t a n t for a c h i e v i n g h e m o s t a s i s i n t h e d e l i c a t e d i s s e c t e d aorta. Finally, b e c a u s e t h e a n a s t o m o t i c s u t u r e line is c l e a r l y v i s i b l e at its c o m p l e t i o n , a d d i t i o n a l s u t u r e s a r e easily p l a c e d . I n c o n s i d e r a t i o n of t h e s e factors, I a m l e d to b e l i e v e t h a t t h e Calla f l o w e r
REVIEW
OF RECENT
1023
m e t h o d of o p e n d i s t a l a n a s t o m o s i s r e p r e s e n t s a v e r y i m p o r t a n t c o n t r i b u t i o n to t h e a r m a m e n t a r i u m of t h e s u r g e o n o p e r a t i n g o n t h e aorta.
Michael Rosenbloom, M D Division of Cardiothoracic Surgery Washington University School of Medicine Suite 3108 One Barnes Hospital Plaza St. Louis, M O 63110
BOOKS
Pathology of the Thymus and Mediastinum By Michael J. Kornstein, MD Philadelphia, Saunders, 1995 245 pp, illustrated, $60.00 ISBN 0-72164-337-X
Reviewed by Thomas W. Shields, MD Doctor Kornstein's monograph, Pathology of the Thymus and Mediastinum, one in a series of Major Problems in Pathology, is primarily directed to the pathologist to provide the newer information on mediastinal disorders that has accumulated over the last several decades. However, thoracic surgeons interested in the surgical aspects of mediastinal disease will find this volume a valuable source of information to enable them to have a greater and more complete understanding of the basic nature of the many pathologic processes that affect this region. Although I do not concur with the "old," and unfortunately ingrained, anatomic divisions of the mediastinum used in the text, this in no way detracts from the value of the material presented by Dr Kornstein. Doctor Kornstein's special interests are immunology and the thymus gland. As a consequence, approximately 45% of the text is devoted to this gland and its diseases. In this section a historical overview, a review of the normal thymus, nonneoplastic pathology of the thymus, and tumors of the thymic epithelial cell are included. It is of interest that Dr Kornstein is critical of the currently popular, at least in some centers, cortical/ medullary classification of thymomas as suggested by MullerHermelink and colleagues and others in the 1980s. His reserva-
© 1996 by The Society of Thoracic Surgeons Published by Elsevier Science lnc
tions as to the value or even applicability of this classification must not be taken lightly. In addition to the thorough coverage of the pathologic aspects of the various thymic diseases, Dr Kornstein succinctly presents the relative clinical, therapeutic, and prognostic information that is important for clinicians or surgeons managing patients with the valious thymic diseases. A minor criticism of mine is the exclusion of consideration of thymic carcinoid from the main section of thymic diseases and its placement in a subsequent later chapter on neuroendocrine tumors that presents both the subjects of thymic carcinoid and paraganglioma. The second largest section is devoted to lymphomas (including Hodgkin's disease) and other hematologic lesions. This chapter is somewhat difficult for the nonpathologist or nonhematologist but may serve as an excellent reference source to the uninitiated in this area of diseases. The clinical material, although brief, is authoritative. The remainder of the text covers metastases, infections, germ cell tumors, tumors of neural origin, mediastinal cysts, pleural tumors, and miscellaneous lesions. The essential features are well presented, but in-depth discussions of these various lesions are lacking. However, the appropriate references to the major new developments in diagnosis and treatment have been amply provided. Finally, throughout the monograph, excellent tables as well as well-reproduced photomicrographs of the various lesions are available as one would expect in such a high-quality volume.
Evanston, Illinois
Ann Thorac Surg 1996;61:1023 • 0003-4975/96/$15.00 SSDI 0003-4975(95)01140-4
During open distal anastomosis for type A dissecting aneurysm, the beveled end of the graft was rolled back like a bract of the Calla flower and inserted into the aortic lumen. The inverted graft was anastomosed using forehand continuous sutures. After completion of the distal anastomosis, the inverted graft was pulled out and then
the proximal anastomosis was completed. This "Calla flower" deformation facilitates the hemostatic distal anastomosis in hemi-arch replacement during open distal anastomosis.
n the surgical treatment of thoracic aneurysm, various techniques have been used for aortic anastomosis. These include the inclusion technique I1], open distal anastomosis [2], elephant trunk [3], and invaginated distal anastomosis [4, 5]. Here we describe an anastomotic technique useful for treatment of type A dissecting aneurysm.
sutures directed the posterior edge of the inverted graft anteriorly with the opened posterior aortic wall, and a strip of Teflon felt was positioned outside the aorta for reinforcement (Fig 1). These posterior edges were easily sutured using a forehand suture with a bloodless field. The anterior edges were sutured using the same technique and the inverted graft was pulled out after completion of the distal anastomosis (Fig 2). Any air was removed from the arch vessels by retrograde cerebral perfusion while the patient remained in a head-down position, and hemostasis was secured by filling the graft with returned blood from the retrograde cerebral perfusion. The graft was then clamped and antegrade cerebral perfusion was resumed through the femoral artery cannula. During p u m p rewarming, the proximal anastomosis was completed and the patient was weaned uneventfully from cardiopulmonary bypass.
I
Technique
A 72-year-old w o m a n underwent hemi-arch replacement for type A dissecting aneurysm. A standard median sternotomy was performed and core cooling was instituted. With circulatory arrest at a core temperature of 19°C, the transverse aortic arch was incised longitudinally near the ligamentum arteriosum and then the cardiopulmonary bypass was slowly resumed through the femoral artery cannula with balloon occlusion of the descending aorta. The three-head vessels were inspected from inside the aortic arch and were found to be uninvolved, leading to the decision to use a hemi-arch graft replacement. The Hemashield woven graft (diameter, 30 ram) was beveled, adjusting the length of the oblique cut to the size of the transected aortic arch. Then the beveled end of the graft was widely rolled back and deformed like a bract of the Calla flower (a flower belonging to the arum family). This inverted graft was placed into the opened transverse aorta and retrograde cerebral perfusion was started. Two stay sutures were placed in the toe and heal of the anastomosis, and a flexible intracardiac suction catheter was inserted into the arch through the graft to aspirate the overflow from retrograde cerebral perfusion. Retraction of the stay Accepted for publication Sep 29, 1995. Address reprint requests to Dr Sakamoto, Department of Cardiothoracic Surgery, School of Medicine, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113, Japan.
© 1996 by The Society of Thoracic Surgeons Published by Elsevier Science lnc
(Ann Thorac Surg 1996;61:1021-3)
Comment
Open distal anastomosis has been widely accepted as a standard technique in operations for thoracic aneurysms. The inversion of the graft within itself ("invagination") was first reported by Griepp and colleagues [4] to anastomose the graft to the proximal descending aorta for arch replacement. Svensson [51 has modified this technique and emphasized that the suture line is automatically tightened after the graft is unfolded, resulting in freedom from bleeding. Hemostasis is not only achieved by the unfolding effect. In addition, the suture increases surface contact area between the graft and the aortic wall [5], and the graft is doubled over on itself with a reduced risk of bleeding at the aortic arch anastomotic site. In a patient with type A dissecting aneurysm, hemiarch replacement was planned, and the beveled end of the graft itself was widely rolled back like a bract of the Calla flower. The more oblique the beveled end of the graft, the larger the bract of the "Calla" becomes, and the 0003-4975/961515.00 SSDI 0003-4975(95)01140-4
1022
H O W TO DO 1T SAKAMOTO ET AL " C A L L A " METHOD FOR OPEN DISTAL ANASTOMOSIS
Ann Thorac Surg 1996;61:1021-3
S (A)
Fig 1. (A) Calla flower, belonging to the arum family. (B) Beveled end of the graft itself is rolled back like a bract of the Calla flower. (C) The inverted graft is placed into the aortic lumen and the anastomosis of the graft to the aorta is carried out with a single continuous suture sandwiching the aorta between the graft on the inside and the Teflon felt on the outside. Fig 2. Intraoperative view of hemi-arch replacement using the Calla method.
space b e t w e e n the suture line a n d the trunk of the graft becomes wider, facilitating a f o r e h a n d continuous suture. In 1969, Pearce a n d colleagues [6] r e p o r t e d a simplified technique to anastomose the three h e a d vessels as a cuff in operation for a n e u r y s m s of the aortic arch, b u t only if the distal aortic arch and the vessels were not involved. H e m i - a r c h r e p l a c e m e n t using the Calla graft technique w o u l d be possible as an alternative simplified method. In a patient with type B dissecting aneurysm, this technique has b e e n also a p p l i e d in total r e p l a c e m e n t of the descending aorta, leaving the Adamkiewicz vessel with a beveled distal thoracic aorta. We are grateful to Dr Juro Wada (Wada Heart and Lung Institute, Tokyo, Japan) and Dr James L. Cox (Division of Cardiothoracic Surgery, Washington University, St. Louis, MO) for their excellent comments in the preparation of this article.
References 1. Bentall H, De Bono A. A technique for complete replacement of the ascending aorta. Thorax 1968;23:338-9. 2. Cooley DA, Livesay JJ. Technique of "open" distal anastomosis for ascending and transverse arch resection. Cardiovasc Dis 1981;8:421-6. 3. Borst HG, Walterbush G, Schaps D. Extensive aortic replacement using "elephant trunk" prosthesis. Thorac Cardiovasc Surg 1983;31:37-40. 4. Griepp RB, Stinson EB, Hollingsworth JF, Buehler D. Prosthetic replacement of the aortic arch. J Thorac Cardiovasc Surg 1975;70:1051-63. 5. Svensson LG. Rationale and technique for replacement of the ascending aorta, arch, and distal aorta using a modified elephant trunk procedure. J Cardiac Surg 1992;7:301-12. 6. Pearce CW, Weichert RF III, del Real RE. Aneurysm of aortic arch. Simplified technique for excision and prosthetic replacement. J Thorac Cardiovasc Surg 1969;58:886-90.
INVITED COMMENTARY
Careful observation of nature has led m a n y a creative m i n d to innovation. In this regard, it is p r o b a b l y no coincidence that the African Calla lily flourishes near the water holes frequented b y e l e p h a n t trunks. The technical challenges of repairing the acutely dissected aorta include the r e a p p r o x i m a t i o n of the friable aortic layers. This is c o m m o n l y p e r f o r m e d by compressing the layers b e t w e e n parallel concentric strips of Teflon felt. In a second step, the r e p a i r e d aorta is a n a s t o m o s e d to a Dacron graft. This portion of the p r o c e d u r e is
typically p e r f o r m e d in an open m a n n e r u n d e r a period of profoundly h y p o t h e r m i c circulatory arrest. The Calla flower technique for aortic repair permits quick repair of the dissection and graft anastomosis in one step. The n e e d for the extra step of r e a p p r o x i m a t i n g the aortic layers with parallel concentric strips of Teflon felt is eliminated. This is because once the Dacron graft is inverted, it b e c o m e s the inner buttressing layer. W h e n the graft is ultimately pressurized, the o u t w a r d force of the blood with the l u m e n causes the aortic wall to be
Ann Thorac Surg 1996;61:1021-3
HOW TO DO IT SAKAMOTOET AL "CALLA" METHOD FOR OPEN DISTAL d~NASTOMOSIS
c o m p r e s s e d b e t w e e n t h e g r a f t a n d t h e o u t e r T e f l o n felt strip. In d o i n g this, h e m o s t a s i s is facilitated. Fortunately, after a personal communication, I had the o p p o r t u n i t y to t e s t t h i s s i m p l e m e t h o d . T h e C a l l a f l o w e r t e c h n i q u e is i n d e e d e x p e d i t i o u s a n d h e m o s t a t i c . T h e m e t h o d also l e n d s itself to t h e u s e of f i n e r s u t u r e m a t e rial, w h i c h m a y b e i m p o r t a n t for a c h i e v i n g h e m o s t a s i s i n t h e d e l i c a t e d i s s e c t e d aorta. Finally, b e c a u s e t h e a n a s t o m o t i c s u t u r e line is c l e a r l y v i s i b l e at its c o m p l e t i o n , a d d i t i o n a l s u t u r e s a r e easily p l a c e d . I n c o n s i d e r a t i o n of t h e s e factors, I a m l e d to b e l i e v e t h a t t h e Calla f l o w e r
REVIEW
OF RECENT
1023
m e t h o d of o p e n d i s t a l a n a s t o m o s i s r e p r e s e n t s a v e r y i m p o r t a n t c o n t r i b u t i o n to t h e a r m a m e n t a r i u m of t h e s u r g e o n o p e r a t i n g o n t h e aorta.
Michael Rosenbloom, M D Division of Cardiothoracic Surgery Washington University School of Medicine Suite 3108 One Barnes Hospital Plaza St. Louis, M O 63110
BOOKS
Pathology of the Thymus and Mediastinum By Michael J. Kornstein, MD Philadelphia, Saunders, 1995 245 pp, illustrated, $60.00 ISBN 0-72164-337-X
Reviewed by Thomas W. Shields, MD Doctor Kornstein's monograph, Pathology of the Thymus and Mediastinum, one in a series of Major Problems in Pathology, is primarily directed to the pathologist to provide the newer information on mediastinal disorders that has accumulated over the last several decades. However, thoracic surgeons interested in the surgical aspects of mediastinal disease will find this volume a valuable source of information to enable them to have a greater and more complete understanding of the basic nature of the many pathologic processes that affect this region. Although I do not concur with the "old," and unfortunately ingrained, anatomic divisions of the mediastinum used in the text, this in no way detracts from the value of the material presented by Dr Kornstein. Doctor Kornstein's special interests are immunology and the thymus gland. As a consequence, approximately 45% of the text is devoted to this gland and its diseases. In this section a historical overview, a review of the normal thymus, nonneoplastic pathology of the thymus, and tumors of the thymic epithelial cell are included. It is of interest that Dr Kornstein is critical of the currently popular, at least in some centers, cortical/ medullary classification of thymomas as suggested by MullerHermelink and colleagues and others in the 1980s. His reserva-
© 1996 by The Society of Thoracic Surgeons Published by Elsevier Science lnc
tions as to the value or even applicability of this classification must not be taken lightly. In addition to the thorough coverage of the pathologic aspects of the various thymic diseases, Dr Kornstein succinctly presents the relative clinical, therapeutic, and prognostic information that is important for clinicians or surgeons managing patients with the valious thymic diseases. A minor criticism of mine is the exclusion of consideration of thymic carcinoid from the main section of thymic diseases and its placement in a subsequent later chapter on neuroendocrine tumors that presents both the subjects of thymic carcinoid and paraganglioma. The second largest section is devoted to lymphomas (including Hodgkin's disease) and other hematologic lesions. This chapter is somewhat difficult for the nonpathologist or nonhematologist but may serve as an excellent reference source to the uninitiated in this area of diseases. The clinical material, although brief, is authoritative. The remainder of the text covers metastases, infections, germ cell tumors, tumors of neural origin, mediastinal cysts, pleural tumors, and miscellaneous lesions. The essential features are well presented, but in-depth discussions of these various lesions are lacking. However, the appropriate references to the major new developments in diagnosis and treatment have been amply provided. Finally, throughout the monograph, excellent tables as well as well-reproduced photomicrographs of the various lesions are available as one would expect in such a high-quality volume.
Evanston, Illinois
Ann Thorac Surg 1996;61:1023 • 0003-4975/96/$15.00 SSDI 0003-4975(95)01140-4