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Ann Thorac Surg 1998;65:1186-1187
© 1998 The Society of Thoracic Surgeons
a Department of Surgery, Columbia University, New York, New York, USA
b Department of Surgery, Allegheny Hospital, Pittsburgh, Pennsylvania, USA
c Department of Surgery, Medical Center of Delaware, Newark, Delaware, USA
Address reprint requests to Dr Lemole, 4745 Stanton-Ogletown Rd, Newark, DE 19713-2070
As Originally Published in 1990:
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We have continued to use the sutureless ring grafts [1] in the management of aortic dissections and aneurysms in both the ascending and descending position. The technique has yielded us excellent short-term results and continues to provide event-free long-term survival. To date, we have had no dehiscences or pseudoaneurysms associated with these grafts in up to 15 years of follow-up.
Between 1978 and 1997, 123 patients underwent replacement of their ascending or arch aorta with a sutureless intraluminal prosthesis. There were 76 male and 47 female patients with ages ranging from 15 to 85 (mean age, 62 years). Sixty-three cases were aortic dissections, including 55 type I and 8 type II dissections. Aneurysmal disease comprised the remaining 60 cases, with 51 ascending and 12 arch aneurysms. Acute dissections occurred in 49 patients, necessitating emergency operations, whereas only 10 emergency operations occurred in the aneurysmal patient group. Forty-seven patients underwent aortic valve replacement, 35 in the aneurysm group and 12 in the dissection group, at the time of their repair. Twenty-three patients required concomitant coronary artery bypass grafting, 12 in the aneurysmal group and 11 in the dissection group.
The mean cross-clamp time for the patients was 54 minutes for ascending aneurysms, 44 minutes for arch aneurysms, 47 minutes for type I dissections, and 40 minutes for type II dissections. Intraoperative transfusion requirements were 4.4 units for ascending aneurysms, 6.4 units for arch aneurysms, 7.1 units for type I dissections, and 5.2 units for type II dissections. Thirty-day operative mortality was 14 of 55 (25%) for type I dissections, 2 of 8 (25%) for type II dissections, 6 of 51 (12%) for ascending aneurysms, and 3 of 9 (33%) for arch aneurysms. A majority of the deaths, 60%, occurred in patients undergoing emergency operations.
Despite this successful clinical experience, the incidence of sutureless ring graft use has declined. Several of the problems for which the ring graft was particularly beneficial have been in large part solved by the availability of collagen-impregnated grafts. These newer generation grafts allow careful suturing to friable tissue with remarkably little postoperative bleeding. For this reason, we rarely use the rings at the proximal end of the ascending aortic graft. Meticulous sculpting of the collagen-impregnated grafts allows a more meticulous anastomosis to the tissue just above the aortic valves and has been quite effective in our experience. Distally, the ability to use a sutureless graft reduces the circulatory arrest time required and provides a secure anastomosis to friable tissue.
Several hints are useful in constructing these anastomoses. Generally a 23-mm aortic valve will fit best into a 24-mm sutureless ring graft. Likewise, when creating composite grafts, a 24-mm ring graft will fit snugly into a 24-mm polytetrafluoroethylene graft. Surgeons should generally undersize the ring because a depressurized aorta will shrink in diameter and make implantation of large rings more difficult. Needless to say, although a 24-mm diameter may seem small for some of these aneurysms, a graft with this diameter creates no degree of flow-limiting stenosis.
The major limitations to worldwide use of these ring grafts result from the antiquated graft material that currently accompanies the rings. These woven Dacron grafts are rarely used in other settings and remain difficult to sew to. Currently, it is not possible to purchase the ring separately, and one is forced to purchase both the sutureless ring graft combination and a separate collagen-impregnated graft to perform the operation that is desired.
References
This article has been cited by other articles:
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  R. S. Bonser, A. M. Ranasinghe, M. Loubani, J. D. Evans, N. M. A. Thalji, J. E. Bachet, T. P. Carrel, M. Czerny, R. Di Bartolomeo, M. Grabenwoger, et al. Evidence, Lack of Evidence, Controversy, and Debate in the Provision and Performance of the Surgery of Acute Type A Aortic Dissection J. Am. Coll. Cardiol., December 6, 2011; 58(24): 2455 - 2474. [Abstract] [Full Text] [PDF]
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