Ann Thorac Surg 1998;66:1436-1437
© 1998 The Society of Thoracic Surgeons
How to Do It
Tube device for facilitating distal anastomosis in aortic arch replacement
Tadahiro Sasajima, MDa,
Kazutomo Goh, MDa,
Hidenori Asada, MDa,
Tokihito Sugawaraa,
Norifumi Ohtani, MDa
a First Department of Surgery, Asahikawa Medical College Hospital, Asahikawa Medical College, Asahikawa, Japan
Accepted for publication June 5, 1998.
Address reprint requests to Dr Sasajima, First Department of Surgery, Asahikawa Medical College, Nishikagura 4-5, Asahikawa, 078 Japan
e-mail: (sasajit{at}asahikawa-med.ac.jp)
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Abstract
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The technique of placing an inverted graft into the descending thoracic aorta facilitates and secures the distal anastomosis in aortic arch replacement, especially in the anastomosis beyond the transverse arch. We developed a simple technique using a pair of thin-walled tubes to enable the arch graft, with its four branches, to be smoothly inserted into the flaccid, normal-caliber descending aorta. The use of these tubes simplified the procedure, resulting in time saving.
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Introduction
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Placing an inverted graft into the descending thoracic aorta (DTA) is the preferred technique for aortic arch replacement [1]; however, it is not easy both to insert the whole of the arch graft, with its four branches, into the flaccid DTA without dilation and to remove it as well. Hence, we developed a simple method that uses a pair of different-caliber, thin-walled tubes to enable the whole of the arch graft to be inserted into the flaccid DTA.
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Technique
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The tube device is made from 0.5 mm-thick, clear, heat-shrinkable polyethylene tubes having inner diameters of 22 and 26 mm (Sumitube; Sumitomo Electric Industries Ltd, Tokyo, Japan), the property of which is changed to hard elastic by heating. The tube device cast consists of a gently curved, 5-cm-long inner tube with one closed end (Fig 1A) and a 10-cm-long outer tube with both ends open, the diameters of which are 18 and 22 mm, respectively. Each tube is heat-shrunk over the respective-sized mandrel by placing it directly over a flame in the range of 80° to 110°C, while the closed end is created by maintaining the heating process. The device is sterilized with ethylene oxide before the operation. At the operation, the adequately trimmed arch graft (Hemashield; Meadox Medicals, Oakland, NJ) is squeezed into the inner tube from the proximal end of the graft by the level of the left subclavian branch (see Fig 1A); the distal end of the graft is then inverted and covers the inner tube (Fig 1B). Finally, the graft is packed into the outer tube and moved by the opposite end (Fig 1C). The tube device with the graft is inserted into the DTA at a sufficient depth, and only the outer tube is removed, leaving the inverted graft in the DTA (Fig 1D). This placement of the inverted graft within the DTA greatly facilitates exposure and makes continuous sutures quite easy and secure (Fig 1E). The inner tube containing the graft with four branches is easily removed from the DTA (Fig 1F).
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Fig 1. (A) The proximal segment of the graft is squeezed into the inner tube. (B) The distal trunk of the graft is turned inside out and envelops the inner tube. (C) The inner tube containing the graft is squeezed into the outer tube. (D) The outer tube containing the graft is inserted into the descending thoracic aorta, and only the outer tube is removed. (E) The graft is placed in the aorta, and distal anastomosis by continuous sutures is performed. (F) After completion of the anastomosis, the inner tube is easily removed from the descending aorta.
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Comment
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Since November 1996, aortic arch replacement using the technique described here has been performed on 7 patients with a distal aortic arch aneurysm or type A dissection at the Asahikawa Medical College Hospital. The procedures for the distal anastomosis were completed within 30 minutes in all cases, resulting in a shortening of about 10 minutes when compared with the method using the cuff graft. The optimal length from the left subclavian branch to the distal end of the graft is 7 to 9 cm when the distal anastomotic site is at the origin of the DTA. Because the tube is translucent, the arch graft can be inserted in the proper position in accordance with the black guide line on the graft (see Fig 1). The tube device also has been applied to the elephant trunk technique [2]. In that case, the reflection fold of the graft in the elephant trunk should be marked in blue before it is packed into the outer tube.
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References
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- Griepp R.B., Stinson E.B., Hollingsworth J.F., Buehler D. Prosthetic replacement of the aortic arch. J Thorac Cardiovasc Surg 1975;70:1051-1063.[Abstract]
- Borst H.G., Frank G., Schaps D. Treatment of extensive aortic aneurysms by a new multiple-stage approach. J Thorac Cardiovasc Surg 1988;95:11-13.[Abstract]
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Abstract
Introduction
