Ann Thorac Surg 1998;66:2121-2122
© 1998 The Society of Thoracic Surgeons
How To Do It
Three-graft technique for ascending aorta and total aortic arch replacement
Gen-ya Yaginuma, MDa,
Yoshiyuki Iijima, MDa,
Kazuo Abe, MDa,
Yoshiyuki Okada, MDa,
Michitoshi Ottomo, MDa
a Department of Cardiovascular Surgery, Yamagata Prefectural Central Hospital, Yamagata, Japan
Accepted for publication June 22, 1998.
Address reprint requests to Dr Yaginuma, Department of Cardiovascular Surgery, Yamagata Prefectural Central Hospital, Sakura-cho 7-17, Yamagata city, Yamagata, 990-8520, Japan
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Abstract
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We have developed a procedure for total aortic arch replacement using three separate Hemashield grafts and establishing deep hypothermic circulatory arrest and continuous retrograde cerebral perfusion followed by antegrade cerebral perfusion. This method is technically simple and yields secure anastomoses.
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Introduction
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Recently, the results of total aortic arch replacement for the acute type A aortic dissection or true aneurysms of aortic arch have much improved [1, 2]. However, the procedure, which uses selective cerebral perfusion, is complicated, with multiple cannulations and a multibranched graft. We have developed a new procedure for total aortic arch replacement to overcome this problem. This method replaces an ascending aorta and an aortic arch by using three separate Hemashield grafts. This technique is simple and can lead to reliable results in total aortic arch replacement.
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Technique
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Cardiopulmonary bypass is established with an arterial cannula placed in the femoral artery and two venous cannulas inserted into both the superior and inferior vena cava. After left ventricular venting, the patient is cooled to a rectal temperature of 18°C. The ascending aorta is incised after establishing deep hypothermic circulatory arrest (DHCA) and cardiac arrest using retrograde blood cardioplegia. Continuous retrograde cerebral perfusion (CRCP) [3] is started at flow rates of 200 to 400 mL/minute through the venous cannula in the superior vena cava to keep central venous pressure at no more than 20 mm Hg. The aortotomy is now extended longitudinally to the aortic arch, and each arch vessel is transected free from the aortic arch. Now the aorta is completely amputated distal to the left subclavian artery.
The anastomoses are made in the following order. First, a graft of 12 mm in diameter is sutured to the transected arch vessels, end-to-end to the left subclavian artery, and end-to-side to the left common carotid and the brachiocephalic arteries with DHCA and CRCP. It should take approximately 20 minutes to complete the three anastomoses, during which CRCP is kept (Fig 1A).
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Fig 1. (A) A graft (12 mm) is sutured to the arch vessels under continuous retrograde cerebral perfusion and deep hypothermic circulatory arrest. (B) The second graft (20–24 mm) is sutured to the descending aorta with open distal anastomosis and modified elephant trunk technique using antegrade cerebral perfusion through the first graft and deep hypothermic circulatory arrest. (C) Continuous retrograde cerebral perfusion is resumed to complete side-to-side anastomosis of the first graft and the second graft with deep hypothermic circulatory arrest.
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Second, through the graft, antegrade cerebral perfusion is started at the flow rate of 10 mL/kg per minute under DHCA. The concept of this cerebral perfusion through the anastomosed graft has been reported by Griepp and Ergin [4]. Hemostasis should be confirmed with all the suture lines. At the second stage, a graft of 20 to 24 mm in diameter is sutured to the proximal end of the descending aorta, by using open distal anastomosis and the elephant trunk technique [5]. The dissected aortic wall is first reinforced by securing a Teflon felt strip to the outside and a short graft (length, 5 cm) to the inside of the aorta, then the second graft is anastomosed to the reinforced aortic stump to complete modified elephant trunk. Completion of this anastomosis takes about 40 minutes, by which time DHCA will have been kept for approximately 60 minutes (Fig 1B).
Third, antegrade cerebral perfusion should be stopped and CRCP resumed to complete side-to-side anastomosis of the first and second grafts with DHCA. This anastomosis should be finished within 10 minutes, for a total DHCA time of approximately 70 minutes (Fig 1C).
Fourth, systemic and cerebral perfusion is restarted through the first graft. All suture lines should be checked for bleeding. Finally, the ascending aorta is reconstructed with a graft 24 to 28 mm in diameter. This third graft is sutured to the aortic root during rewarming and it should take 30 minutes to complete. At completion of the anastomosis, blood cardioplegia is infused through an aortic occlusion balloon catheter with an infusion port inserted into the graft to check hemostasis of the suture line. The last anastomosis between the second and third grafts is done in 10 minutes (Fig 2A). If the proximal aortic size is not much larger than the second graft, a direct anastomosis between them can be done. In total, aortic clamp time is 110 minutes, CRCP, 30 minutes, antegrade cerebral perfusion, 40 minutes, and DHCA, 70 minutes (Fig 2B).
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Fig 2. (A) The ascending aorta is reconstructed with the third graft (24–28 mm). (B) Completion of all anastomoses for ascending aorta and total aortic arch replacement.
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Comment
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When a branched graft and selective cerebral perfusion are used simultaneously for total arch replacement, the surgical field might become too crowded for inexperienced surgeons to assist effectively. To conquer the problem, we have developed a procedure, which is technically very simple, and its advantages are as follows: (1) Anastomoses can be done easily without a branched graft and multiple cannulations that disturb the surgical view and suture technique. (2) Blood leakage from suture lines can be examined after each anastomosis. (3) The second graft size can be chosen to match the distal aortic size, and the third graft size to match the proximal aortic size. The size discrepancy between graft and aorta is minimal so that each anastomosis is secure. (4) By using this procedure, an extra margin of time is available within the safety limits of brain protection. Continuous retrograde cerebral perfusion in this procedure lasts about 30 minutes. The reported time limit of brain protection is 85 minutes [6], therefore, a margin of 55 minutes is allowed.
We have used this procedure in two patients, 56 and 49 years old, with acute type A aortic dissection. Each operation took approximately 6 hours, and both patients survived. An ordinary total arch replacement procedure with selective cerebral perfusion and hypothermia of 25°C in our hospital takes about 4 hours. This time difference between the two methods is probably caused by the difference in the hypothermic temperatures.
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Acknowledgments
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We would like to thank Mari Tahara for helpful suggestions.
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References
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Tabayashi K., Niibori K., Iguchi A., Shoji Y., Ohmi M., Mohri H. Replacement of transverse aortic arch for type A acute aortic dissection. Ann Thorac Surg 1993;55:864-867.[Abstract/Free Full Text]
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Kazui T., Kimura N., Yamada O., Komatsu S. Surgical outcome of aortic arch aneurysm using selective cerebral perfusion. Ann Thorac Surg 1994;52:904-911.
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Ueda Y., Miki S., Kusuhara K., Okita Y., Tahara T., Yamanaka K. Surgical treatment of aneurysm of dissection involving the ascending aorta and aortic arch, utilizing circulatory arrest and retrograde cerebral perfusion. J Cardiovasc Surg 1990;31:553-558.[Medline]
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Griepp R.B., Ergin M.A. Aneurysms of the aortic arch. In: Edmunds L.H., ed. Cardiac surgery in the adult. New York: McGraw-Hill, 1996:1197-1226.
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Borst H.G., Walterbusch G., Schaps D. Extensive aortic replacement using "elephant trunk" prosthesis. Thorac Cardiovasc Surg 1983;31:37-40.[Medline]
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Kouchoukos N.T. Adjuncts to reduce the incidence of embolic brain injury during operation on the aortic arch. Ann Thorac Surg 1994;57:243-245.[Abstract/Free Full Text]
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Abstract
Introduction
