Ann Thorac Surg 1996;61:869-873
© 1996 The Society of Thoracic Surgeons
Original Article: Cardiovascular
``Legs'' Technique for Management of Widely Separated Coronary Arteries During Ascending Aortic Repair
Noel L. Mills, MD,
Dan A. Morgenstern, MD,
Vincent A. Gaudiani, MD,
Felix Ordoyne, Rnfa
Mills Cardiovascular, New Orleans, Louisiana
Accepted for publication November 6, 1995.
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Abstract
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Background. Widely separated coronary arteries with significantly diseased tissue continues to challenge surgeons repairing ascending aortic aneurysms.
Methods. Occasional troublesome leaks around coronary ostial anastomoses and Cabrol graft thrombosis prompted a change of our operative management of this condition. Collagen-impregnated 8-mm ``legs'' grafts are used to connect the coronary arteries to the composite graft. Ten patients, aged 14 to 70 years, underwent the operation.
Results. The first patient is 15 years after operation and is symptom free. One patient died of an arrhythmia 1 month after discharge. Eight patients are living and well 1
to 4 years postoperatively.
Conclusions. Advantages of direct interposition (legs) grafts are as follows: the coronary arteries are separately perfused and the risk of catastrophic thrombosis from a longer high-volume graft is eliminated. Problems with coronary ostial mobilization are avoided. The technique allows full visualization and hemostatic suture line testing with cardioplegia before aortic declamping. Space constraints with reoperations are easily managed, whereas other techniques may result in graft compression on refilling of the heart and termination of bypass. The technique is carried out with ease and reproducibility, and the availability of new graft material has made it our treatment of choice for ascending aortic composite graft replacement.
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Introduction
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See also page 874.
Replacement of the ascending aorta for aneurysm, dissection, aortoannular ectasia, or variants thereof has become commonplace in cardiac surgery. Despite the passage of time since the original descriptions of ascending aortic replacement [1, 2], the procedure still represents a formidable challenge to surgeons, particularly in regard to coronary artery reconstruction when there are widely displaced coronary arteries or significantly diseased aortic tissue. The geometry of the heart receiving cardioplegia changes significantly upon cardiac refilling and rewarming and at times causes unanticipated suture line stress.
Numerous large series in the literature have documented the problems of bleeding [3–9], distortion [10], pseudoaneurysm formation [6–8, 11–14], thrombosis [11], kinking [11, 15], and coronary damage [5]. Several techniques for management of the coronary arteries have evolved since the original Bentall procedure. These include aortic button anastomoses [16] and the Cabrol interposition graft [17]. Other variations on these surgical themes have been reported, more as solutions to operative difficulties than as new procedures.
We have encountered occasional problems in past operations with troublesome leaks around the coronary ostia when inclusion or button techniques were used (Fig 1
). In 2 relatively recent patients who underwent the Cabrol modification, coronary graft thrombi developed even with large graft-to-graft anastomoses and adequate anticoagulation. This experience plus a review of a case operated on 15 years ago prompted a reassessment of our operative management of the coronary arteries.
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Fig 1. . Technical problems due to stretch may occur, as in severe aortoannular ectasia. Bleeding may occur at anastomotic sites with the ``button'' technique, especially with severely diseased tissues and widely spaced coronary arteries. High first septal perforator coronary arteries (arrow) may become occluded with unclamping and resumption of heartbeat. (LAD = left anterior descending artery; RCA = right coronary artery.)
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We have applied the lessons learned from our experience and the literature and report a simple, easily reproducible modification that we believe incorporates the positive contributions of many operative strategies.
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Material and Methods
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Operative Technique
Access to the ascending aorta is via routine median sternotomy. Cannulation for cardiopulmonary bypass is standard by way of single two-stage venous cannulation of the right atrium and most commonly the left femoral artery. Flow rate, core temperature, and myocardial preservation are likewise a function of the anatomic situation as well as the philosophy of the surgeon. The ascending aorta is opened and the lesion(s) examined. After excision of the aortic valve, an appropriately sized valved conduit (St. Jude Medical Inc, St. Paul, MN) is selected and, to aid in later hemostasis, is prepared by 25% albumin impregnation and autoclaving. (Appropriate-sized prosthetic valved conduits that are collagen impregnated are used now that they are commercially available in this country.) During the autoclave time period, an 8-mm-diameter Hemashield graft (Meadox Medicals, Inc, Oakland, NJ) is cut approximately 40 cm long and is anastomosed end-to-end to the left coronary ostium with a running 4-0 polyproplyene suture (Fig 2A). An appropriately sized ``washer'' of thin Teflon felt is fashioned and placed on the graft before the anastomosis is begun (Fig 2B). It is incorporated between the graft and the coronary side of the continuous suture line as a buttress. The other end of the Hemashield graft is anastomosed to the right coronary ostium in a similar fashion. The integrity of these suture lines is then checked by direct infusion of cardioplegic solution into the middle of the graft with a 15-gauge needle (Fig 3). For the remainder of the operation great care is taken to avoid any tension on these anastomoses. The composite graft, ie, valved conduit, is next sewn into place at the aortic annulus using the preferred suture technique of the surgeon. Our preference is interrupted 2-0 Tycron suture with buttresses in the supraanular position.
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Fig 2. . (A) One end of a 40-cm-long, 8-mm Hemashield graft is anastomosed to the orifice of the left coronary artery using 4-0 polypropylene suture. A previously cut felt ring has been slipped over the graft and is incorporated in the suture line. (B) The suture surrounds the ``felt washer'' to ensure a tight seal in diseased aortic tissue. (RCA = right coronary artery.)
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Fig 3. . After a similar anastomosis is made with the opposite end of the 8-mm graft to the right coronary orifice, the integrity of the suture lines is checked by direct infusion of cardioplegic solution into the graft with a 15-gauge needle.
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After these maneuvers, the 8-mm Hemashield graft is divided at an appropriate distance from the left coronary anastomosis in preparation for its anastomosis to the composite graft. This graft length (leg) varies from patient to patient and is usually 1 to 2 cm when unstretched. A hand-held, battery-operated eye cautery is used to create an 8-mm-diameter hole in the composite graft at an appropriate level from the annulus such that the Hemashield extension of the coronary graft lies without torsion or kink. A running 4-0 Tevdek or polyproplyene suture is used to construct an anastomosis from the end of the Hemashield graft to the side of the valved conduit (Fig 4). Next, the right coronary end (leg) is trimmed appropriately and anastomosed to the anterior side of the valved conduit. All proximal suture lines are then tested by infusion of cardioplegic solution into the clamped composite aortic graft. The latter is transected at the appropriate length and anastomosed to the distal aorta (Fig 5). An external thin felt strip is used for reinforcing that suture line. When an acute dissection is present, more elaborate techniques may be used to effect a secure suture line, eg, interposition of felt strips or resorcinol glue. Rewarming, deairing, separation from cardiopulmonary bypass, and decannulation are then performed in a routine manner. With resumption of cardiac function, the short, knitted, collagen-impregnated Dacron graft is noted to be very forgiving with movement during the cardiac cycle without incurring a kink or obstruction in side-to-side or superior-to-inferior angulation as the heart and coronary arteries resume their normal position (Fig 6).
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Fig 4. . After the valved conduit has been sutured to the aortic annulus, the 8-mm graft is transected at an appropriate distance from the left coronary anastomosis. A continuous 4-0 Tevdek suture is used to anastomose the 8-mm graft at a suitable level to the valved conduit.
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Fig 5. . After the right coronary graft is transected and anastomosed at the proper level to the conduit with the technique used for the left coronary circulation, the suture lines are tested by infusion of cardioplegic solution into the distally clamped composite aortic graft. Finally, the conduit is transected and anastomosed to the distal ascending aorta. This completes the ``legs'' modification for ascending aortic–coronary reconstruction.
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Fig 6. . The softness and the ``accordionization'' ability of the short, knitted, collagen-impregnated Dacron ``legs'' is noted to be very forgiving without incurring a kink or obstruction in side-to-side or superior-to-inferior angulation on unclamping and cessation of cardiopulmonary bypass. (LCA = left coronary artery; RCA = right coronary artery.)
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The 8-mm collagen-impregnated graft material is knitted, and therefore it is easy to pass a 4-0 polypropylene needle and suture through it without incurring the fulcrum stresses on diseased tissue as noted with stiff woven material. No preclotting is necessary. We observed that when ten rings of the graft are fully compressed, it measures 10 mm long. When that same segment is allowed to relax and expand, it becomes 23 mm long. If the same segment is maximally stretched it is 36 mm long, thereby giving an extreme degree of latitude to avoid technical mishap. Likewise, when 20-mm and 30-mm compressed segments are studied, geometrically similar characteristics are observed. Kinking is virtually impossible even with short 270-degree turns.
Clinical Material
Attention was focused on the technique of using short separate grafts to each ostium for management of the coronary arteries during ascending aortic composite graft reconstruction by a patient who returned after such an operation performed by one of us 15 years earlier. Stiff, low-porosity 10-mm Dacron graft had been used for coronary reconstruction due to an unusually long distance (10 cm) between the origin of the coronary arteries secondary to severe aortoannular ectasia. A repeat angiogram before the recent mitral valve replacement revealed an excellent functional and anatomic result from the operation. Nine additional consecutive patients more recently had this technical modification performed to make a total of 10 patients who form the basis for this review. Ages ranged from 14 years to 70 years, and all except 1 patient were male. Eight patients had coronary ostia widely separated from the center of the aortic root (7 to 11.5 cm). Two patients (1 with atherosclerosis and a second with postoperative fibrosis) had coronary ostia within normal distance from the aortic center point. Four patients had aortoannular ectasia, 3 patients had Marfan's disease, 2 had medial necrosis, and 1 had atherosclerosis as the cause of their ascending aortic aneurysms. Three patients had acute ascending aortic dissections. Two patients with coronary artery disease had concomitant single and double saphenous vein coronary bypass grafts. Two patients had previous mitral valve replacements. A 37-year-old man with Marfan's syndrome and severe aortic insufficiency had three previous cardiac operations (two mitral valve replacements and one mitral valve replacement plus an ascending aortic replacement.) The composite valve graft reconstruction described herein was performed by one of us (V.A.G.) and modified with 8-mm ``legs'' due to severe fibrosis and room constraints that made the usual Cabrol modification or ``button'' technique impossible.
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Results
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All patients survived the operation without any major complications and were discharged 6 to 10 days postoperatively. One 14-year-old patient with preoperative ventricular arrhythmias, severe left ventricular dysfunction (ejection fraction = 0.20), mild mitral insufficiency, and a chronic pericarditis of unknown cause succumbed to an arrhythmia 1 month after discharge. The remaining 9 patients are symptom free and are maintained on a regimen of sodium warfarin (Table 1). Follow-up has been 1.5 to 4 years in 8 patients. All echocardiograms (mean, 15 months) show no evidence of suture line failure or other aneurysm formation. Ascending aortic angiography at 2 years on 1 patient and at 15 years for the patient who returned for mitral valve replacement likewise revealed no abnormalities.
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Comment
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The reports by Bentall and De Bono [1] and Edwards and Kerr [2] opened the way to surgical replacement of the ascending aorta for a variety of pathologic processes. However, it became apparent that several significant problems were associated with the original Bentall procedure and, in particular, with the handling of the coronary arteries. Bleeding at the reimplanted coronary suture lines [3–9] and the distal anastomosis remains a problem, evidenced by advertisement of a hemostatic wrap in this journal. Distortion of the coronary geometry [10] and the formation of pseudoaneurysms has been documented [6–8, 11–14]. Several remedies were proposed [15] including the use of an aortic button for reimplantation of the coronary arteries [17], and many abandoned the inclusion technique [12]. Cabrol and associates [3, 17] described the use of a Dacron interposition graft and connected both coronary ostia to the composite graft by means of a single side-to-side anastomosis. However, reports [11] of thrombosis of the right limb of the graft, intraoperative occlusion of the right coronary artery, and kinking of the Cabrol graft at the level of the left ostium were forthcoming. These problems as well as kinking at the point of the graft-to-graft attachment point out that this procedure has its drawbacks. Najafi [18] reported on 2 patients who had widely separate coronary ostia treated with saphenous vein graft interposition. Zubiate and Kay [19] approached the problem of widely separated coronary artery orifices by closing the coronary arteries proximally and using saphenous vein grafts from the ascending aortic graft to the distal coronary arteries. The now known limited longevity of saphenous grafts makes these techniques outdated. Piehler and Pluth [20], in 5 of 26 cases where there was insufficient mobility of the left ostium for direct reimplantation, used a short segment of 6-mm Gore-Tex (W.L. Gore & Assoc, Flagstaff, AZ) from the left coronary artery to the side of the composite graft.
Recently, Neveux and associates [21] described a technique to combat the problem of coronary ostia that cannot reach the composite valve graft at a satisfactory level for direct reimplantation. Their technique involves making a hole in the Dacron conduit that conserves the prosthetic wall as a flap of aortic prosthesis. A trap door effect is thereby created with a lower hinge. Left and right coronary ostia reimplantation is performed. Tension on the suture line is avoided, although from their illustrations, it appears that potentially diseased sinus tissue is incorporated in the repair.
The advantages of 8-mm interposition grafts (legs) are as follows: each coronary artery is perfused by a separate short graft that contours easily as opposed to other materials. Thus the risk of catastrophic thrombosis and kink from a single, longer, higher volume graft is eliminated. The ``accordion'' morphology of the soft, collagen-impregnated material allows for tension-free movement during the cardiac cycle. The vagaries (eg, spasm, injury, torsion) of coronary ostial mobilization are avoided as is the problem of kinking of an early arising first septal perforating coronary artery (see Fig 1
). The technique allows full visualization for hemostasis and testing of all proximal suture lines under pressure using antegrade cardioplegia. In the event of a reoperation to replace a nonvalved or valved conduit (for example, failed porcine bioprosthesis) space constraints due to fibrosis or adhesions are easily managed with short ``legs,'' whereas a Cabrol graft modification may result in graft compression on filling of the heart and cessation of cardiopulmonary bypass. ``Buttons'' may be virtually impossible to safely mobilize without tension or injury to surrounding structures due to the fibrosis. The ``user friendly'' material does not have the propensity for graft atherosclerosis or kinking as do saphenous vein grafts.
In conclusion, we have been impressed with the ease, reproducibility, and adaptability of a ``legs'' modification for management of the coronary arteries during composite aortic valve--ascending aorta reconstruction when the coronary arteries are widely separated. The availability of knitted, collagen-impregnated material is clearly advantageous over previous stiff grafts that tend to kink. Clearly longer follow-up is required to validate the use of this procedure. Given the fact that the operation is an amalgamation of previously proven operative techniques with improved graft material, we are optimistic that good long-term results will be forthcoming.
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Footnotes
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Address reprint requests to Dr Mills, Tulane University School of Medicine, Department of Surgery, SL22, 1430 Tulane Ave, New Orleans, LA 70112.
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References
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- Edwards WS, Kerr AR. A safer technique for replacement of the entire ascending aorta and aortic valve. J Thorac Cardiovasc Surg 1970;59:837–9.[Medline]
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- Gallotti R, Ross DN. The Marfan syndrome: surgical technique and follow up in 50 patients. Ann Thorac Surg 1980;29:428–33.[Abstract]
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- Miller DC, Stinson EB, Oyer PE, et al. Concomitant resection of ascending aortic aneurysms and replacement of the aortic valve. Operative and long-term results with ``conventional'' techniques in 90 patients. J Thorac Cardiovasc Surg 1980;79:388–401.[Abstract]
- Cabrol C, Pavie A, Mesnildery P, et al. Long term results with total replacement of the ascending aorta and reimplantation of the coronary arteries. J Thorac Cardiovasc Surg 1986;91:17–25.[Abstract]
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- Zubiate P, Kay JH. Surgical treatment of aneurysm of the ascending aorta with aortic insufficiency and marked displacement of the coronary ostia. J Thorac Cardiovasc Surg 1976;71:415–21.[Abstract]
- Piehler JM, Pluth JR. Replacement of the ascending aorta and aortic valve with a composite graft in patients with nondisplaced coronary ostia. Ann Thorac Surg 1982;33:406–9.[Abstract]
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Abstract
Introduction
