Ann Thorac Surg 1998;65:1255-1259
© 1998 The Society of Thoracic Surgeons
Surgical Treatment of Aortic Dissections: Initial Experience With the Adventitial Inversion Technique
Raúl García-Rinaldi, MD, PhDa,
Jorge Carballido, MDa,
Joaquín Mojica, MDa,
Ernesto R. Soltero, MDa,
Slavisa Curcic, MDa,
José Barceló, MDa,
Raúl Porro, MDa
a Divisions of Cardiovascular Surgery, Anesthesia, and Perfusion, Pavía Heart Institute, San Juan, Puerto Rico
Accepted for publication December 5, 1997.
Address reprint requests to Dr García-Rinaldi, PO Box 19868, Fernández Juncos Station, San Juan, Puerto Rico 00910.
e-mail: garciarinald{at} isla.net
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Abstract
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Background. The adventitial inversion technique obliterates the false lumen and converts a dissected aorta into a conduit with tough adventitia on the inside and outside. Dacron grafts can be anastomosed to the aorta with fine sutures, which hold without tears.
Methods. From August 1995 to March 1997, we treated 6 patients with acute dissecting aneurysms. Three aneurysms were type I (A) involving the entire aorta, two type II (A) involving the ascending aorta, and one type III (B) involving the thoracoabdominal aorta. Circulatory arrest was used in 3 patients, 1 with type I aneurysm (A), 1 type II (A), and 1 type III (B).
Results. All Dacron–aorta anastomoses held sutures well and did not bleed intraoperatively or postoperatively. One patient (type II [A]) died of intraoperative low cardiac output. In patients with type I (A) aneurysms, the false lumen was obliterated, but 1 patient required resection of a 6-cm abdominal aortic aneurysm.
Conclusions. The adventitial inversion technique is a safe technique for the treatment of acute dissecting aneurysms, which facilitates operation and solves the problem of intraoperative or postoperative bleeding due to tissue friability.
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Introduction
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Aortic dissections and dissecting aortic aneurysms are among the most serious problems encountered in clinical practice. Acute rupture, secondary organ or system involvement, associated irreversible complications, and tissue friability complicate treatment [1, 2]. Although the techniques to manage aortic disease are well established and widely available, mortality and morbidity of surgical treatment are high because of organ damage and anastomotic complications such as bleeding and dehiscence [3].
Floten and colleagues [3] described the adventitial inversion technique used to reinforce the remainder of the aorta at the anastomotic site. Because the adventitia and its adjacent elastic laminae remain intact and are tough, infolding of this layer results in a dramatic change in the characteristics of the proximal and distal aortic segments. This technique, which can be used in dissections that extend into the transverse arch, converts the dissected aorta into a tough but soft cuff for anastomosis [3]. Perhaps as important, the surgeon using this technique obliterates the false lumen at its site of origin [3].
The results of Floten and associates [3] were exceptional, with a 7.1% mortality in 28 patients. Unexplainably, the technique did not receive much attention in the literature or at national meetings specifically dealing with diseases of the aorta.
We describe our initial experience, expanding the indications for use of this novel technique for all types of dissecting aneurysms. It complements the experience of Floten and colleagues with 6 patients with dissecting aortic aneurysms by using the DeBakey [4] and Stanford classifications [5]. All the anastomoses were easy to construct, the duration of circulatory arrest was minimal, and none of the anastomoses bled intraoperatively or postoperatively.
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Material and methods
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Type I (Stanford A) dissecting aortic aneurysms
For type I (Stanford A) dissecting aortic aneurysms, the patient is cannulated (Fig 1A). The femoral artery used for perfusion is determined at the time of cardiac catheterization or we use the artery with a diminished or absent pulse that most likely will perfuse the true lumen [6]. Cardiopulmonary bypass is begun at 60 mL · kg-1 · min-1 flow, and the systemic temperature is lowered to 18°C, if circulatory arrest is used.
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Fig 1. Perfusion circuits used for repair of dissecting aneurysms. (A) The circuit used for types I and II (Stanford A). (B) The circuit used for type III (Stanford B) aneurysms.
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We use retrograde crystalloid cardioplegia to arrest the heart unless we are absolutely certain that the needle used to infuse antegrade cardioplegia is in the true lumen. The aorta is cross-clamped immediately below the innominate artery (Fig 2). The aorta is transected and the site of intimal rupture identified. Proximally and distally, the intima is separated from the adventitia, which is pulled back about 1.5 cm from the edge (see Fig 2A). The intima is then transected 1.0 cm proximally and distally. The adventitia is turned inside, over the intima, and tacked with interrupted 5-0 polypropylene sutures placed from the inside and tied on the outside (see Fig 2B). Leaving a few sutures uncut to use as guides in constructing the aortic cuff is helpful. The proximal aortic cuff is prepared while the systemic temperature is lowered. In our experience, all type I (A) dissecting aortic aneurysms have originated so distal to the coronary ostia that adventitial inversion has not compromised them. One could encounter a situation with a more proximal tear that would then require the use of techniques such as valved conduits or coronary bypass grafts.
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Fig 2. Repair of type I and II (Stanford A) dissecting aneurysms with use of circulatory arrest. (A) The aorta is transected and adventitia is separated completely from the intima. The damaged intima is divided proximally and distally at least 1 cm from the site of rupture. (B) The adventitia is inverted over the intima and tacked with 5-0 interrupted polypropylene sutures. (C) Open anastomosis with 4-0 polypropylene sutures is performed. (D) Antegrade perfusion through a side arm graft is begun and the patient is warmed. (E) Completed repair.
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Preparation of each aortic cuff takes about 10 minutes. We begin preparation of the distal cuff with the 5-0 polypropylene sutures before reaching the target systemic core temperature. If needed, the distal anastomosis can be completed using circulatory arrest without the aortic clamp to perform an open anastomosis and allow inspection inside of the aortic arch. A collagen-impregnated Dacron prosthesis is used without Teflon buttresses, biologic glues, or topical glutaraldehyde [1, 7–10].
The anastomosis, done with a continuous 4-0 polypropylene suture, is easy to perform and is usually hemostatic. Occasionally one or two interrupted 5-0 polypropylene sutures are used for complete hemostasis. Contrary to the established Teflon "sandwich" technique [1], which results in a "hard" aortic cuff that requires the use of large, thick needles, this procedure results in a soft adventitial cuff. Retrograde aortic flow is restarted to test the anastomosis. A 10-mm collagen-impregnated prosthesis is sutured in end-to-side fashion to the aortic prosthesis, and antegrade flow is reestablished to immediately stop retrograde flow through the false lumen (see Fig 2C). Rewarming is started, and the proximal anastomosis is constructed with continuous polypropylene suture (see Fig 2E).
Other aneurysms that may have formed (eg, in the infrarenal aorta) are treated surgically at a future date if they exceed 4.0 cm in diameter. For infrarenal aneurysms, the abdominal aorta is transected (fenestration operation) and the anastomosis is performed on the outer aortic layer [2, 11].
Type II (Stanford A) dissecting aortic aneurysms
The repair of type II (Stanford A, localized to ascending aorta) can be simple or complex, depending on the amount of damage caused by the dissecting process. Dissections localized to the ascending aorta, such as those encountered during cardiac catheterization, are relatively easy to repair with use of the adventitial inversion technique (see Fig 2B). For type II (Stanford A) aneurysms, we use the perfusion circuit shown in Figure 1A. The aorta is cross-clamped at the level of the innominate artery, and the proximal cuff is prepared with the adventitial inversion technique. The distal cuff is performed using circulatory arrest, if necessary, to allow inspection of the transverse arch of the aorta. Anastomosis to a Dacron-impregnated prosthesis is accomplished with 4-0 polypropylene sutures, using the technique described above. This results in a strong, hemostatic suture line.
We illustrate a case of a type II (Stanford A) dissection that resulted in severe aortic insufficiency and rupture (shearing off) of the right coronary artery (Fig 3). The patient presented with an evolving inferior myocardial infarction. Distally, the preparation of the aortic cuff was relatively simple with the adventitial inversion technique and clamping the aorta below the innominate artery. Because of extensive damage to the aortic valve and transection of the right coronary artery, we elected to use a valved conduit. The left coronary artery was anastomosed directly to the ascending graft. The right coronary artery was ligated proximally, and a distal venous bypass was constructed. The vein bypass was anastomosed proximally to the uninvolved innominate artery. The anastomoses were completely hemostatic.
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Fig 3. Repair of a complex type II (Stanford A, localized to ascending aorta) aneurysm without circulatory arrest. (A) Dissection process has destroyed the aortic root and sheared off the right coronary artery. (B) The intima is divided proximally and distally; the adventitia is inverted over it. (C) A valved conduit is used proximally to reconstruct the aortic root. The right coronary artery is ligated. (D) The innominate right coronary bypass is performed; repair is completed.
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Type III (Stanford B) dissecting aortic aneurysms
We use circulatory arrest as proposed by Caramutti and colleagues [12] to handle type III (Stanford B) dissecting aneurysms. Circulatory arrest provides ample space without clamps to construct a perfect cuff in a bloodless field.
We use the perfusion circuit shown in Figure 1B. The pulmonary artery or outflow track is cannulated or one can cannulate the femoral vein with a long venous cannula. Deep hypothermia (16° to 18°C) is induced and circulatory arrest is instituted (Fig 4). The aorta is opened without the use of clamps. The aorta is transected distal to the subclavian artery, and the adventitia is inverted as described previously (see Figs 4B, 4C). A collagen-impregnated Dacron graft with a 10-mm collagen-impregnated Dacron graft sutured end to side is anastomosed with continuous 4-0 polypropylene suture (see Fig 4C). Upon completion of the proximal anastomosis, femoral flow is resumed slowly to evacuate air from the arch of the aorta and the graft. Cerebral and myocardial flow are reestablished through the side arm graft (see Fig 4C). The patient is rewarmed while the distal anastomosis is performed. The adventitia is inverted distally to obliterate the false lumen. The graft is then anastomosed to the aortic cuff with a continuous 4-0 polypropylene suture. Upon evacuation of air from the graft, perfusion is discontinued through the femoral artery and continued through the thoracic graft until the patient can be weaned from cardiopulmonary bypass (see Figs 4C, 4D).
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Fig 4. Repair of type III (Stanford B) dissecting aneurysms. (A) Extent of damage. Dissection extends into upper abdominal aorta. (B) The patient is positioned in a right lateral decubitus position with hips extended. We use the perfusion circuit illustrated in Figure 1B and open repair under circulatory arrest. The adventitia is inverted over the intima, and the anastomosis to the graft is accomplished with 4-0 polypropylene sutures. (C) Cerebral and myocardial perfusion is resumed through a side arm graft, and the patient is warmed. (D) The distal anastomosis is performed after the adventitia has been inverted; repair is completed.
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Results
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From August 1995 to March 1997, we treated 6 patients (4 men) with acute dissecting aneurysms. Three aneurysms were type I (Stanford A), involving the entire aorta; two were type II (Stanford A), involving the ascending aorta; and one was type III (Stanford B) involving the thoracoabdominal aorta. Circulatory arrest was used in 3 patients (Table 1): 1 with type I aneurysm (Stanford A), 1 type II (A), and 1 type III (Stanford B). One patient with type II (Stanford A, localized to ascending aorta), in whom the right coronary artery was sheared off, required the implantation of a valved conduit and a coronary artery bypass. All 11 Dacron–aorta anastomoses held sutures well and did not bleed intraoperatively. Bleeding from the operative site did not exceed 400 mL in 24 hours. None of the patients sustained neurologic injury. In 1 patient with type III (Stanford B), who presented with paralysis, pulmonary insufficiency developed and necessitated a tracheostomy. He died of unrelated causes 3 months after operation.
One patient (type II, Stanford A, localized to ascending aorta), who required the valved conduit, died of intraoperative low cardiac output syndrome. In the 3 patients with type I (Stanford A) aneurysms, the false lumen was completely obliterated. However, 1 patient required a resection of a 6-cm abdominal aortic aneurysm. At the time of presentation, the false lumen was thrombosed. No new aneurysms have developed. The patients are followed up by computed tomographic scans of the thoracic and abdominal aorta every 6 to 12 months.
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Comment
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The repair of spontaneous dissecting aortic aneurysms or iatrogenic aortic dissections can be very complex because of the extreme friability of the aortic tissue, the extent of damage to structures, and in many cases, secondary organ involvement [1, 2]. Many techniques have been used to reinforce the friable aortic tissue. Teflon felt has been amply used, but many times the resultant aortic cuff is tough and of small size. Bleeding from this graft–"sandwiched" aorta can be troublesome. Resorcinol glue, although extremely useful to reinforce the aortic tissues [7, 8], is not available in the United States. Topical 25% glutaraldehyde, as described by Vasseur and Hamond [9] for dissecting aneurysms and later by us for friable aortas [10], is very effective in toughening aortic tissue. However, the procedure of applying the glutaraldehyde is tedious, and it can damage the surrounding tissue.
The adventitial inversion technique described by Floten and colleagues [3] is an effective method of modifying the friable aorta to create a tough but soft aortic cuff. The toughness ensures that the sutures hold without tearing. The softness allows the use of small needles and sutures to facilitate a hemostatic anastomosis. Their remarkably low (7.1%) mortality [3] alerted us to the versatility of this technique.
Dissecting aneurysms can create practically unsolvable surgical situations. Our experience expands the use of the adventitial inversion technique to other complex surgical situations. Thus, most patients can be handled with the techniques outlined here. None of the 11 aortic cuff–graft anastomoses bled intraoperatively or postoperatively.
We recommend this simple technique to repair dissecting aneurysms, because it has changed our perception and approach to this highly complex problem. Our experience is small; thus, it is difficult to draw meaningful conclusions about the universal applicability of the technique and long-term results. However, in 1995, Floten and colleagues [3] had treated 29 patients with excellent results in the short- and long-term follow-up.
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References
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- Crawford E.S., Crawford J.L. Diseases of the aorta, 1st ed. Baltimore: Williams and Wilkins, 1984:168-214.
- DaGama A.D. The surgical management of aortic dissection: from uniformity to diversity, a continuous challenge. J Cardiovasc Surg 1991;32:141-153.[Medline]
- Floten H.S., Ravichandran P.S., Furnary A.P., et al. Adventitial inversion technique in repair of aortic dissection. Ann Thorac Surg 1995;59:771-772.[Abstract/Free Full Text]
- DeBakey M.E., Henly W.S., Cooley D.A., et al. Surgical management of dissecting aneurysm of the aorta. J Thorac Surg 1965;49:130-149.
- Daily P.O., Trueblood H.W., Stinson E.B., et al. Management of acute aortic dissections. Ann Thorac Surg 1970;10:237-247.[Medline]
- Yun K.L., Miller D.C. Technique of aortic valve preservation in acute type A aortic dissection. Operative Techniques in Cardiac & Thoracic Surgery 1996;1:68-81.
- Guilmet D., Bachet J., Goudot B., et al. Use of biological glue in acute aortic dissection. J Thorac Cardiovasc Surg 1979;77:516-518.[Abstract]
- Fabiani J.D., Jebara V.A., Deloche A., et al. Use of surgical glue without replacement in the treatment of type A aortic dissection. Circulation 1989;80(suppl 1):264-268.
- Vasseur B., Hamond G.L. New technique for repair of ascending thoracic aortic dissections. Ann Thorac Surg 1989;47:318-319.[Abstract]
- García-Rinaldi R., Carballido J., Mojica J., et al. The use of 25% glutaraldehyde solution to strengthen the aorta of patients with annuloaortic ectasia, ascending and aortic arch aneurysms. J Cardiovasc Surg 1995;10:262-263.
- Hunter J.A., Dye W.S., Javid H., et al. Abdominal aortic resection in thoracic dissection. Arch Surg 1976;111:1258-1262.[Abstract/Free Full Text]
- Caramutti V.M., Dantur J.R., Favaloro M.R., et al. Deep hypothermia and circulatory arrest as an elective technique in the treatment of type B dissecting aneurysm of the aorta. J Cardiovasc Surg 1989;4:206-215.
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Abstract
Introduction
