Ann Thorac Surg 1998;65:546
© 1998 The Society of Thoracic Surgeons
Case Reports
Simultaneous Total Aortic Replacement Without a Sternotomy Incision
Norihiko Shiiya, MD,
Keishu Yasuda, MD,
Toshifumi Murashita, MD,
Yoshiro Matsui, MD,
Shigeyuki Sasaki, MD
Department of Cardiovascular Surgery, Hokkaido University Hospital, Sapporo, Japan
Accepted for publication September 16, 1997.
Dr Shiiya, Department of Cardiovascular Surgery, Hokkaido University Hospital, N14W5, Kita-ku, Sapporo 060, Japan.
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Abstract
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Total aortic replacement is preferably performed by staged operations, and reports of a simultaneous operation are few. In these reports, both a median sternotomy and a thoracoabdominal incision are employed. We report a patient who successfully underwent simultaneous total aortic replacement without a sternotomy incision. The technique and the feasibility of the operation are discussed.
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Introduction
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Diffuse aneurysmal diseases and multiple aneurysms sometimes require total aortic replacement, which is frequently and preferably performed by staged operations [1]. However, there are some instances in which a single operation is necessary. Total aortic replacement in a single stage has been reported by Massimo and colleagues [2] and Svensson and associates [3]. They used both a median sternotomy with or without a T incision and a thoracoabdominal incision. We report a patient with a DeBakey IIIb postdissection aneurysm, in whom retrograde type A aortic dissection that occurred during the operation necessitated simultaneous total aortic replacement without a sternotomy incision. The technique and the feasibility of the operation are reported.
A 60-year-old woman was admitted to our service for surgical treatment of a chronic expanding DeBakey IIIb aortic dissection. Computed tomographic scans revealed a postdissection aneurysm that extended from the origin of the left subclavian artery to the aortic bifurcation, with a maximum diameter of 64 mm. The aortogram confirmed the diagnosis (Fig 1).
On September 13, 1996, she underwent the operation. The patient was placed in a semilateral spiral position with the left scapula retracted anteriorly with an adhesive. The entire thoracoabdominal aorta was exposed through a thoracoabdominal incision that crossed the costal margin in the sixth intercostal space and extended down along the lateral border of the rectus abdominis muscle. The pleural cavity was entered through the fifth intercostal space. A total retroperitoneal approach with circumferential division of the left hemidiaphragm was used for the exposure of the abdominal aorta. Our initial plan of operation was a modification of the DeBakey operation, in which the distal end of an elongated Dacron tube graft was anastomosed end-to-side to the left common iliac artery, which was followed by an end-to-end anastomosis of the proximal end of the graft to the distal aortic arch under partial cardiopulmonary bypass. However, when the aortic clamp was placed between the left common carotid artery and left subclavian artery, the aortic arch began to be lacerated. Therefore the patient was cooled down to a rectal temperature of 20°C and an esophageal temperature of 15°C for repair under circulatory arrest. During perfusion cooling, a second venous cannula was added into the pulmonary artery, because the femoral venous cannula was a small-bore (21F) one. The left ventricle was vented through the ventricular apex. Under total circulatory arrest, the proximal end of the graft was anastomosed to the aorta just distal to the left common carotid artery. Then blood flow was restored, and the left subclavian artery and the intercostal arteries at T7–10 were reconstructed while the hypothermia was maintained. The visceral branches and the intercostal/lumbar arteries at T12–L1 were reconstructed during the rewarming period, and the abdominal aorta was closed just above the bifurcation. The period of circulatory arrest was 56 minutes.
Although the ascending aorta and the proximal aortic arch initially seemed intact, retrograde type A aortic dissection became apparent after the patient was fully rewarmed and the heartbeat was recovered. At this stage of the operation, we decided to replace the entire aorta. The patient was cooled down again to a rectal temperature of 21°C. After the circulation was arrested, the ascending aorta and the aortic arch were opened, and a circumferential dissection was present. The ascending aorta was transected at the level of aortic valve commissures. Then selective cerebral perfusion was established to the innominate artery that was also circumferentially dissected and to the left common carotid artery with a balloon catheter, systemic flow was restored with a clamp on the proximal end of the descending aortic graft, and cold blood cardioplegia was given directly into the two coronary orifices. A gelatin-resorcin-formalin glue was applied to reapproximate the dissected aortic wall of the transected aorta, and a 26-mm-diameter Dacron tube graft was anastomosed to it. After this graft was connected to the proximal end of the descending aortic graft, the clamp was removed and the heart was reperfused. The two remaining brachiocephalic vessels were then reconstructed with separate tube grafts. The period of circulatory arrest was 10 minutes and the selective cerebral perfusion time was 240 minutes. Cardiopulmonary bypass time for the entire procedure was 672 minutes.
The postoperative course was complicated by excessive bleeding, which required reexploration for removal of the extraperitoneal hematoma on the 5th postoperative day. Ventilatory support was also prolonged. Although the patient was taken off the ventilator on the 14th postoperative day, a tracheotomy was required on the 16th postoperative day for control of pneumonia. The tracheotomy was finally closed on the 59th postoperative day. The patient eventually recovered with no neurologic complication, and is leading a normal life now. Fig 2 shows the postoperative magnetic resonance angiogram and a schematic drawing of the operation.
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Comment
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Total aortic replacement in a single stage remains a challenge for vascular surgeons, because it requires exposure of the entire aorta and protection of all the vital organs from ischemia. Exposure of the ascending aorta and the proximal aortic arch and myocardial protection are easiest through a median sternotomy, whereas the exposure of the thoracoabdominal aorta is best achieved through a thoracoabdominal incision. Therefore two or three separate incisions were used in the previous reports [3], especially when the aortic valve and the aortic root needed to be replaced [2]. However, a sternotomy combined with a thoracotomy adds to the risk of respiratory morbidity in our experience, and a single-incision approach is superior if safe aortic reconstruction and secure organ protection could be assured.
In the present report, we showed the feasibility of total aortic replacement without a sternotomy incision. Once the circulation was arrested and the patient was exsanguinated, the exposure of the ascending aorta at the level of valve commissures was not difficult and protection of the brain and myocardium could safely be performed through a thoracoabdominal incision. Massimo and associates [4] and Crawford and colleagues [5] have also reported the feasibility of reconstruction of the ascending aorta and aortic arch through a thoracotomy incision. However, Kieffer and associates [6] have pointed out that reconstruction of the proximal aorta may be technically hazardous or impossible in some cases and bleeding may be uncontrollable once cardiac activity has resumed. Although we believe that semilateral positioning of the patient and division of the costal margin may, at least in part, resolve this problem, we agree that exposure of the aortic root is not always optimal, and aortic valve replacement or insertion of a composite graft may be impossible [5]. Therefore this approach should be reserved for selected patients in whom an uncomplicated proximal aortic procedure is expected.
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References
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- Crawford ES, Coselli JS, Svensson LG, Safi HJ, Hess KR Diffuse aneurysmal disease (chronic aortic dissection, Marfan, and mega aorta syndromes) and multiple aneurysm. Treatment by subtotal and total aortic replacement emphasizing the elephant trunk operation. Ann Surg 1990;211:521-537.[Medline]
- Massimo CG, Presenti LF, Favi PP, Crisci C, Cruz Guadron EA Simultaneous total aortic replacement from valve to bifurcation: experience with 21 cases. Ann Thorac Surg 1993;56:1110-1116.[Abstract/Free Full Text]
- Svensson LG, Shahian DM, Davis FG, et al. Replacement of entire aorta from aortic valve to bifurcation during one operation. Ann Thorac Surg 1994;58:1164-1166.[Abstract/Free Full Text]
- Massimo CG, Poma AG, Viligiardi RR, Duranti A, Colucci M, Favi PP Simultaneous total aortic replacement from arch to bifurcation: experience with six cases. Tex Heart Inst J 1986;13:147-151.
- Crawford ES, Coselli JS, Safi HJ Partial cardiopulmonary bypass, hypothermic circulatory arrest, and posterolateral exposure for thoracic aortic aneurysm operation. J Thorac Cardiovasc Surg 1987;94:824-827.[Abstract]
- Kieffer E, Koskas F, Walden R, et al. Hypothermic circulatory arrest for thoracic aneurysmectomy through left-sided thoracotomy. J Vasc Surg 1994;19:457-464.[Medline]
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Abstract
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