Use of cuffed anastomosis in total aortic arch replacement

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%.     

The "eaves" technique for distal anastomosis in aortic arch replacement

We describe the “eaves” technique, a new method for distal anastomosis in aortic arch replacement. The 1-cm wide eaves were created at the site 3 to 4 cm distal to the graft end. The graft was bound with vessel tape from the eaves to the site proximal to the origin of the first branch to make a working space above the eaves and to facilitate graft handling. Then the native descending aorta was sutured to the eaves easily. The eaves enabled a greater surface contact area between the graft and the inner wall of the aorta and reduced bleeding at the anastomosis.     

Total arch replacement for a distal aortic arch aneurysm with right aortic arch

Right-sided aortic arch accompanied by an aberrant origin of the left subclavian artery is rare and seen in 0.05% approximately 0.1% of the population. A 73-year-old woman with this anomaly was admitted to our institution because of the enlargement of the distal aortic arch aneurysm. She also had mild dysphagia. The size of the aneurysm was 70 mm in diameter and she underwent total arch replacement using selective cerebral perfusion through a median sternotomy. Additional right thoracotomy was not required and four cervical vessels were reconstructed. The postoperative course was uneventful. This case report shows median sternotomy alone may provide sufficient access for this pathology.     

Distal aortic perfusion during aortic arch reconstruction: another tool for the aortic surgeon

Complex aortic arch reconstruction remains one of the greatest challenges facing cardiothoracic surgeons today. Deep hypothermic circulatory arrest is the most common technique for open arch replacement. Either antegrade or retrograde cerebral perfusion is often utilized in an attempt to decrease neurologic complications. In addition to cerebral perfusion, we have employed continuous perfusion of the thoracic aorta to minimize spinal cord, visceral, and lower extremity ischemia. This approach does not significantly increase the complexity of the operative procedure while reducing the ischemic time of critical areas, which may lead to improved patient outcomes.     

Anterior approach to traumatic mid aortic arch transection

The majority of nonpenetrating traumatic injuries to the thoracic aorta are fatal. Survivors of aortic transection tend to have injuries occurring at the isthmus. We report a rare, blunt traumatic complete transection of the mid aortic arch between the innominate and left common carotid arteries diagnosed by multidetector computed tomography of the chest. The repair was approached anteriorly and required aortic arch replacement.     

Up to 7 years' experience with valve-sparing aortic root remodeling/reimplantation for acute type A dissection

BACKGROUND: Aortic valve-sparing operations for acute type A dissection are appealing and innovative but less well defined surgical techniques requiring further evaluation. METHODS: We reviewed all consecutive patients with acute type A dissection who underwent either the remodeling (group 1, n = 21) or the reimplantation valve-sparing technique (group 2, n = 15) since October 1994. Patients were followed up clinically and echocardiographically for as long as 41.3 months (group 1) and 87 months (group 2). RESULTS: Hospital mortality was 19% (n = 4) for group 1 and 20% (n = 3) for group 2. Permanent new neurologic symptomatology occurred in 1 patient (3.6%). Three patients in group 1 required reoperation owing to redissection. No patient had an aortic insufficiency of more than grade 1. No late neurologic or thrombembolic events occurred. There was no statistically significant difference between both groups with respect to clinical and hemodynamic data. CONCLUSIONS: Remodeling and reimplantation aortic valve-preserving operations in acute type A dissection can be performed with adequate perioperative risk and excellent midterm aortic valve function. We found no evidence of one technique being superior to the other, however durability of the remodeling technique needs critical consideration especially in Marfan syndrome and when glue is used.     

Total aortic arch replacement through the L-incision approach

BACKGROUND: Even though the median sternotomy is the standard approach for surgery involving the aortic arch, access to the site of distal anastomosis is problematic when the aortic pathology involves the distal arch. We recently developed an "L-incision" approach (a combination of a left anterior thoracotomy and upper half median sternotomy) for total arch replacement. METHODS: We reviewed our surgical technique and operative results for 11 patients who underwent total aortic arch replacement through the L-incision between July 1999 and July 2000. With a patient in a left anterolateral position, a left anterior thoracotomy was performed through the fourth to sixth intercostal space. An upper half median sternotomy followed. Operative exposure was enhanced with spring retractors. The proximal anastomosis (between the four branched graft and ascending aorta) was accomplished first. Upon completion of the proximal anastomosis, the heart was reperfused from one branch of the graft. The three arch vessels were subsequently reconstructed under deep hypothermia and retrograde cerebral perfusion. Antegrade cerebral perfusion was accomplished through the graft as the distal anastomosis (between the graft and descending thoracic aorta) was performed. RESULTS: No early operative deaths were observed. One patient sustained a permanent neurologic deficit. A transient recurrent laryngeal nerve palsy lasting 1 month occurred in 1 patient. No patient required reoperations for bleeding, nor did any patient develop a postoperative phrenic nerve palsy, aspiration pneumonia, or renal dysfunction. CONCLUSIONS: The L-incision allows extensive replacement of the aortic arch and is associated with a low incidence of postoperative bleeding and respiratory insufficiency.     

Arch-first technique for aortic arch aneurysm repair through median sternotomy

We describe a modified arch-first technique for total arch replacement through median sternotomy. This technique involves a short period of circulatory arrest (less than 30 minutes) and subsequent anterior cerebral perfusion. It does not require cannulation of the carotid vessels, which can cause cerebral thromboembolism, and it enables anterior cerebral perfusion to be resumed after a relatively short period of circulatory arrest. This appears to be a useful technique to reduce cerebral complications in complicated arch reconstruction operation for patients with severely atherosclerotic carotid vessels.     

A novel arch-first T-graft technique for extensive aortic arch reconstruction

To reduce the morbidity and mortality associated with extensive aortic arch replacement, the reconstruction technique is the most important part of the treatment. By refining the present techniques, we developed an arch-first T-graft technique. This technique provides a more reasonable arrangement of procedures, least brain ischemic time, less low-body ischemic time, and an easy way of distal aortic anastomosis. This method is performed through a traditional median sternotomy, keeps the lung free from manipulation, and avoids severe kink of major vascular grafts.