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Use of cuffed anastomosis in total aortic arch replacement
Use of Cuffed Anastomosis in Total Aortic Arch Replacement Katsuhiko Oda, MD, Hiroji Akimoto, MD, Masaki Hata, MD, Junetsu Akasaka, MD, Kazuhiro Yamaya, MD, Atsushi Iguchi, MD, and Koichi Tabayashi, MD Department of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
CASE REPORTS
The distal aortic anastomosis portion of the total arch surgery remains technically complex especially in cases in which an aortic arch aneurysm extends below level of carina. We present the cuffed anastomosis that overcomes this difficulty. We applied this technique in 49 patients of
elective total aortic arch aneurysm repair using selective cerebral perfusion from 1996 to 2001. Hospital mortality was 2%. (Ann Thorac Surg 2003;76:952–3) © 2003 by The Society of Thoracic Surgeons
D
The brachiocephalic artery, left carotid artery, and left subclavian artery were end-to-end-anastomosed with each branched prosthetic graft, respectively. This simple method was used in 41 cases of true aortic arch aneurysm and 8 cases of chronic dissecting aneurysm. The hospital mortality was 2%. The cause of only 1 patient death was multiorgan failure.
espite advances in surgical technique, the distal aortic anastomosis portion of total arch surgery remains technically complex, and perioperative bleeding remains problematic. In cases in which an aortic arch aneurysm extends below the level of carina, the distal anastomosis becomes especially difficult by median sternotomy alone and may require left thoracotomy to prevent anastomotic bleeding. Close opposition of the phrenic nerve and recurrent nerve also pose difficulties and requires special care to prevent phrenic nerve palsy and subsequent respiratory dysfunction. Several techniques have been advocated for distal aortic anastomosis, including open distal anastomosis [1], elephant trunk [2], invaginated distal anastomosis [3, 4], and the Calla method [5]. We began using the cuffed technique for distal aortic anastomosis in December 1996. Forty-nine consecutive patients underwent this procedure safely.
Technique Open distal anastomosis was performed at 22°C during selective cerebral perfusion, and trimming of the distal end of the aorta was performed through a posterior wall incision to avoid phrenic and recurrent nerve injury. The distal anastomoses of the aortic arch were performed by the following methods: two or three U stay sutures were placed between the graft (outside-in) and the distal end of the aorta (inside-out) evenly. The graft was rolled back approximately 5 mm. This inverted graft was placed into the opened distal end of the aorta. The suture line was observed circumferentially and easily anastomosed with 4-0 polypropylene sutures (Fig 1). The four-branched, gelatin-coated woven Dacron (C.R. Bard, Haverhill, PA) graft was used for arch replacement. The proximal aortic anastomosis was also performed by the cuffed technique. Accepted for publication Feb 14, 2003. Address reprint requests to Dr Oda, Department of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan; e-mail: [email protected].
© 2003 by The Society of Thoracic Surgeons Published by Elsevier Inc
Comment DeBakey and colleagues reported the first successful replacement of the proximal aortic arch in 1957. At that time, mortality of aortic arch replacement procedures was more than 40%. These early patients suffered from postoperative cerebral accidents and bleeding from imperfect prosthetic grafts. Over the next half century, various modifications to this procedure were undertaken to improve outcomes, and recent reports estimate mortality at 10%. Our series had a 2% hospital mortality rate. Several key modifications have resulted in these improved patient outcomes. Cerebral protection has bene-
Fig 1. Technique of cuffed anastomosis. Two or three U-stay sutures were placed between the graft (outside-in) and the distal end of the aorta (inside-out) evenly. The graft was rolled back approximately 5 mm in length. This inverted graft was placed into the opened distal end of the aorta. The suture line was circumferentially observed and easily anastomosed with 4-0 polypropylene sutures. 0003-4975/03/$30.00 PII S0003-4975(03)00446-6
fited from deep hypothermia associated with circulatory arrest, selective cerebral perfusion (SCP), and retrograde cerebral perfusion. Selective cerebral perfusion (used in our series) consists of independent perfusion of each cerebral hemisphere using two separate pumps, thereby preventing watershed infarction and avoiding perfusion of a false lumen that may complicate acute aortic dissection repair [6]. Although the left carotid artery cannula was in the operating field during use of SCP, its presence was not overly cumbersome. While preoperative cerebrovascular disease and prolonged SCP time (longer than 120 minutes) proved to be risk factors for postoperative cerebral accidents, but we believe that our results with this procedure were acceptable. The ideal anastomotic technique results in absence of bleeding, stenosis, and other injury. The distal arch anastomosis tends to be complicated because of the depth of the surgical field, and thus, open distal anastomosis has been widely accepted as a standard technique. The inversion of the graft within itself was first reported by Griepp and colleagues [3], in which a graft was anastomosed to the proximal descending aorta during aortic arch replacement. Svensson [4] modified this technique and emphasized that the suture line is automatically tightened after the graft is unfolded, resulting in freedom from bleeding. The suture increases surface contact area between the graft and the aortic wall, and the graft is doubled over on itself, leading to a reduced risk of bleeding at the aortic arch anastomotic site. Sakamoto and colleagues [5] described the Calla method for distal anastomosis of hemiarch replacement. We applied a modification of this method to distal aortic anastomosis in true aneurysm and dissection. This cuffed anastomosis minimized the risk of surgical bleeding of the distal anastomotic site. The expected suture line was formed by native aorta and
HOW TO DO IT ODA ET AL CUFFED ANASTOMOSIS FOR ARCH SURGERY
953
inverted artificial graft after approximation with two stay sutures. Suturing and placing additional stitches for hemostasis was technically simple. As a result, this technique was effective in reducing intra- and postoperative bleeding. Preservation of respiratory function is also critical for improved patient outcome following this procedure and is dependent on avoidance of direct lung contusion, phrenic nerve injury, and pulmonary edema. Because the cuffed anastomosis allows for distal aortic anastomosis without left thoracotomy, direct lung injury is prevented. Further, using the posterior wall incision of the aortic arch avoids contact with the phrenic nerve. Because massive bleeding is prevented with this procedure, as described above, volume overload and subsequent pulmonary edema secondary to transfusion does not occur. Indeed, use of this procedure resulted in reduced mechanical ventilation time and length of intensive care unit stay.
References 1. Cooley DA, Livesay JJ. Technique of “open” distal anastomosis for ascending and transverse arch resection. Cardiovasc Dis 1981;8:421–6. 2. Borst HG, Walterbush G, Schaps D. Extensive aortic replacement using “elephant trunk” prosthesis. Thorac Cardiovasc Surg 1983;31:37–40. 3. Griepp RB, Stinson EB, Hollingsworth JF, Buehler D. Prosthetic replacement of the aortic arch. J Thorac Cardiovasc Surg 1975;70:1051–63. 4. Svensson LG. Rationale and technique for replacement of the ascending aorta, arch, and distal aorta using a modified elephant trunk procedure. J Cardiovasc Surg 1992;7:301–12. 5. Sakamoto T, Yoshida T, Sugano T, et al. Simplified technique for hemi-arch replacement during open distal anastomosis: the Calla method. Ann Thorac Surg 1996;61:1021–3. 6. Tabayashi K, Ohmi M, Togo T, et al. Aortic arch aneurysm repair using selective cerebral perfusion. Ann Thorac Surg 1994;57:1305–10.
CASE REPORTS
Ann Thorac Surg 2003;76:952–3
CASE REPORTS
The distal aortic anastomosis portion of the total arch surgery remains technically complex especially in cases in which an aortic arch aneurysm extends below level of carina. We present the cuffed anastomosis that overcomes this difficulty. We applied this technique in 49 patients of
elective total aortic arch aneurysm repair using selective cerebral perfusion from 1996 to 2001. Hospital mortality was 2%. (Ann Thorac Surg 2003;76:952–3) © 2003 by The Society of Thoracic Surgeons
D
The brachiocephalic artery, left carotid artery, and left subclavian artery were end-to-end-anastomosed with each branched prosthetic graft, respectively. This simple method was used in 41 cases of true aortic arch aneurysm and 8 cases of chronic dissecting aneurysm. The hospital mortality was 2%. The cause of only 1 patient death was multiorgan failure.
espite advances in surgical technique, the distal aortic anastomosis portion of total arch surgery remains technically complex, and perioperative bleeding remains problematic. In cases in which an aortic arch aneurysm extends below the level of carina, the distal anastomosis becomes especially difficult by median sternotomy alone and may require left thoracotomy to prevent anastomotic bleeding. Close opposition of the phrenic nerve and recurrent nerve also pose difficulties and requires special care to prevent phrenic nerve palsy and subsequent respiratory dysfunction. Several techniques have been advocated for distal aortic anastomosis, including open distal anastomosis [1], elephant trunk [2], invaginated distal anastomosis [3, 4], and the Calla method [5]. We began using the cuffed technique for distal aortic anastomosis in December 1996. Forty-nine consecutive patients underwent this procedure safely.
Technique Open distal anastomosis was performed at 22°C during selective cerebral perfusion, and trimming of the distal end of the aorta was performed through a posterior wall incision to avoid phrenic and recurrent nerve injury. The distal anastomoses of the aortic arch were performed by the following methods: two or three U stay sutures were placed between the graft (outside-in) and the distal end of the aorta (inside-out) evenly. The graft was rolled back approximately 5 mm. This inverted graft was placed into the opened distal end of the aorta. The suture line was observed circumferentially and easily anastomosed with 4-0 polypropylene sutures (Fig 1). The four-branched, gelatin-coated woven Dacron (C.R. Bard, Haverhill, PA) graft was used for arch replacement. The proximal aortic anastomosis was also performed by the cuffed technique. Accepted for publication Feb 14, 2003. Address reprint requests to Dr Oda, Department of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan; e-mail: [email protected].
© 2003 by The Society of Thoracic Surgeons Published by Elsevier Inc
Comment DeBakey and colleagues reported the first successful replacement of the proximal aortic arch in 1957. At that time, mortality of aortic arch replacement procedures was more than 40%. These early patients suffered from postoperative cerebral accidents and bleeding from imperfect prosthetic grafts. Over the next half century, various modifications to this procedure were undertaken to improve outcomes, and recent reports estimate mortality at 10%. Our series had a 2% hospital mortality rate. Several key modifications have resulted in these improved patient outcomes. Cerebral protection has bene-
Fig 1. Technique of cuffed anastomosis. Two or three U-stay sutures were placed between the graft (outside-in) and the distal end of the aorta (inside-out) evenly. The graft was rolled back approximately 5 mm in length. This inverted graft was placed into the opened distal end of the aorta. The suture line was circumferentially observed and easily anastomosed with 4-0 polypropylene sutures. 0003-4975/03/$30.00 PII S0003-4975(03)00446-6
fited from deep hypothermia associated with circulatory arrest, selective cerebral perfusion (SCP), and retrograde cerebral perfusion. Selective cerebral perfusion (used in our series) consists of independent perfusion of each cerebral hemisphere using two separate pumps, thereby preventing watershed infarction and avoiding perfusion of a false lumen that may complicate acute aortic dissection repair [6]. Although the left carotid artery cannula was in the operating field during use of SCP, its presence was not overly cumbersome. While preoperative cerebrovascular disease and prolonged SCP time (longer than 120 minutes) proved to be risk factors for postoperative cerebral accidents, but we believe that our results with this procedure were acceptable. The ideal anastomotic technique results in absence of bleeding, stenosis, and other injury. The distal arch anastomosis tends to be complicated because of the depth of the surgical field, and thus, open distal anastomosis has been widely accepted as a standard technique. The inversion of the graft within itself was first reported by Griepp and colleagues [3], in which a graft was anastomosed to the proximal descending aorta during aortic arch replacement. Svensson [4] modified this technique and emphasized that the suture line is automatically tightened after the graft is unfolded, resulting in freedom from bleeding. The suture increases surface contact area between the graft and the aortic wall, and the graft is doubled over on itself, leading to a reduced risk of bleeding at the aortic arch anastomotic site. Sakamoto and colleagues [5] described the Calla method for distal anastomosis of hemiarch replacement. We applied a modification of this method to distal aortic anastomosis in true aneurysm and dissection. This cuffed anastomosis minimized the risk of surgical bleeding of the distal anastomotic site. The expected suture line was formed by native aorta and
HOW TO DO IT ODA ET AL CUFFED ANASTOMOSIS FOR ARCH SURGERY
953
inverted artificial graft after approximation with two stay sutures. Suturing and placing additional stitches for hemostasis was technically simple. As a result, this technique was effective in reducing intra- and postoperative bleeding. Preservation of respiratory function is also critical for improved patient outcome following this procedure and is dependent on avoidance of direct lung contusion, phrenic nerve injury, and pulmonary edema. Because the cuffed anastomosis allows for distal aortic anastomosis without left thoracotomy, direct lung injury is prevented. Further, using the posterior wall incision of the aortic arch avoids contact with the phrenic nerve. Because massive bleeding is prevented with this procedure, as described above, volume overload and subsequent pulmonary edema secondary to transfusion does not occur. Indeed, use of this procedure resulted in reduced mechanical ventilation time and length of intensive care unit stay.
References 1. Cooley DA, Livesay JJ. Technique of “open” distal anastomosis for ascending and transverse arch resection. Cardiovasc Dis 1981;8:421–6. 2. Borst HG, Walterbush G, Schaps D. Extensive aortic replacement using “elephant trunk” prosthesis. Thorac Cardiovasc Surg 1983;31:37–40. 3. Griepp RB, Stinson EB, Hollingsworth JF, Buehler D. Prosthetic replacement of the aortic arch. J Thorac Cardiovasc Surg 1975;70:1051–63. 4. Svensson LG. Rationale and technique for replacement of the ascending aorta, arch, and distal aorta using a modified elephant trunk procedure. J Cardiovasc Surg 1992;7:301–12. 5. Sakamoto T, Yoshida T, Sugano T, et al. Simplified technique for hemi-arch replacement during open distal anastomosis: the Calla method. Ann Thorac Surg 1996;61:1021–3. 6. Tabayashi K, Ohmi M, Togo T, et al. Aortic arch aneurysm repair using selective cerebral perfusion. Ann Thorac Surg 1994;57:1305–10.
CASE REPORTS
Ann Thorac Surg 2003;76:952–3