Ann Thorac Surg 2000;69:1951-1953
© 2000 The Society of Thoracic Surgeons
Case reports
Midline exposure of the thoracoabdominal aorta
Takashi Kunihara, MDa,
Norihiko Shiiya, MDa,
Yasuhiro Kamikubo, MDa,
Yoshiro Matsui, MDa,
Keishu Yasuda, MDa
a Department of Cardiovascular Surgery, Hokkaido University Hospital, Sapporo, Japan
Address reprint requests to Dr Shiiya, Department of Cardiovascular Surgery, Hokkaido University Hospital, N14W 5, Kita-ku, Sapporo 060-8648, Japan
e-mail: shiyanor{at}med.hokudai.ac.jp
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Abstract
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Extended aortic replacement from the aortic arch to the descending thoracic or thoracoabdominal aorta has been performed through a left thoracotomy or a thoracoabdominal incision combined with or without a median sternotomy. However, a left thoracotomy incision may be unfavorable when dense adhesion of the lung is anticipated. We report a redo patient who underwent simultaneous replacements of the aortic arch and the thoracoabdominal aorta through a midline incision without entering the left pleural cavity.
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Introduction
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Extended repair of the thoracic or the thoracoabdominal aorta has preferably been performed by staged operations [1], because a single-stage operation requires extended exposure of the diseased aorta and a long duration of procedure which frequently results in excessive bleeding and respiratory morbidity. However, there may be an instance that a single-stage operation cannot be avoided. Although simultaneous replacement of multiple or diffuse aortic aneurysms has recently been performed with favorable results [2–5], dense adhesion in the pleural cavity may preclude its safe application to a redo patient. We report a patient who underwent simultaneous replacement of the aortic arch and the thoracoabdominal aorta through a midline incision, without entering the left pleural cavity, who had a history of prosthetic replacement of the descending thoracic aorta.
A 67-year-old man was admitted to our department on September 11, 1998. He complained of back pain and hemoptysis, and had a history of prosthetic replacement of the descending thoracic aorta on May 24, 1995. Radiological examinations revealed saccular aneurysms on the distal aortic arch with maximum diameter of 70 mm and the thoracoabdominal aorta at the level of diaphragm with maximum diameter of 75 mm (Fig 1A). Considering the risk of rupture of the remaining aneurysm during the interval of the two-stage operation, we selected a simultaneous operation. To minimize the operative stress resulting from a combined sternotomy and thoracoabdominal incision, and to avoid problems resulting from lung adhesion, we decided to repair both aneurysms through a midline incision without entering the left pleural cavity.
The operation was carried out on October 16, 1998. The patient was placed in a supine position and a full median sternotomy combined with an upper laparotomy was performed. Cardiopulmonary bypass was established between an ascending aortic cannula and a single venous cannula. During core cooling, the heart was displaced to the right, the diaphragm was divided in the midline up to the aortic hiatus, and the pericardial incision was extended superiorly behind the heart (Fig 2A). The esophagus was encircled and the thoracoabdominal aortic aneurysm was exposed. When the rectal temperature reached 21°C, selective cerebral perfusion was established into the three vessels at a rate of 600 ml/min and a cardioplegic solution was given. Systemic blood perfusion was arrested to obtain a bloodless, undisturbed operative field by a clamp. A beveled distal end of a 22 mm Dacron tube was anastomosed to the transected supraceliac abdominal aorta to preserve the 11th intercostal arteries. After the proximal anastomosis was completed, blood flow to the abdominal aorta was resumed through a 10 mm side branch of the Dacron tube with a clamp placed proximal to it. The change in the evoked spinal cord potentials during the reconstructive period showed complete recovery after reperfusion. Replacement of the ascending aorta and entire aortic arch was then carried out with a 22 mm Dacron prosthesis with four side branches (Fig 2B). Operation time, cardiopulmonary bypass time, aortic cross-clamp time, and circulatory arrest time were 661, 309, 145, and 55 minutes, respectively.
The postoperative course was uneventful with no respiratory or neurological complications. A postoperative magnetic resonance angiogram showed that both aneurysms were completely replaced by the prostheses (Fig 1B).
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Comment
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Simultaneous repairs of aortic arches and descending thoracic or thoracoabdominal aortae have been performed through left thoracotomies or thoracoabdominal incisions [2, 4, 5]. In patients who also require procedures on the ascending aortae or the aortic roots, median sternotomy incisions have usually been added [2, 4]. However, these kind of operations frequently result in excessive bleeding and respiratory morbidities. Alternatively, Minale and his associates [3] have reported a single-stage replacement of the entire thoracic aorta through a median or a transverse sternotomy incision. They widely opened the pleura and divided the pulmonary ligament. However, if a patient has a history of aortic surgery through a left thoracotomy, dense adhesion of the lung may complicate the operation which adds to the risk of extensive aortic replacement. Therefore, an approach that provides a good exposure of the aorta without entering the pleural cavity may be optimal in this situation.
In this report, we show the feasibility and the technique of the midline exposure of the thoracoabdominal aorta without entering the left pleural cavity. Because the aneurysm was localized to the level of the diaphragm, exposure and replacement of it was not difficult through this approach while the heart was arrested and displaced to the right. Preservation of the critical intercostal arteries was also possible. For a more extensive aneurysm, however, this approach is not recommended because access to a more proximal portion of descending thoracic aorta is impossible without entering a pleural cavity. Therefore, this approach should be reserved for aneurysms in which the proximal neck is located distal to the level of pulmonary hilus. Another possible application for this approach is for aneurysms that extend from the distal aortic arch or more proximal aorta to the distal descending thoracic or supraceliac abdominal aorta, which may be treated by the "retrograde pull-through technique" described by Cooley [6].
The major limitation of the technique is difficulty in controlling bleeding from the aorta behind the heart while the heartbeat has resumed. Despite this limitation, we believe that this approach may be a useful alternative in selected candidates.
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References
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Crawford E.S., Coselli J.S., Svensson L.G., Safi H.J., Hess K.R. 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]
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Massimo C.G., Perna A.M., Cruz Quadron E.A., Artounian R.V. Extended and total simultaneous aortic replacement. J Card Surg 1997;12:261-269.[Medline]
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Minale C., Splittgerber F.H., Reifschneider H.J. Replacement of the entire thoracic aorta in a single stage. Ann Thorac Surg 1994;57:850-855.[Abstract/Free Full Text]
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Svensson L.G., Shahian D.M., Davis F.G., 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]
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Shiiya N., Yasuda K., Murashita T., Matsui Y., Sasaki S. Simultaneous total aortic replacement without a sternotomy incision. Ann Thorac Surg 1998;65:546-548.[Abstract/Free Full Text]
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Cooley D.A. Retrograde replacement of the thoracic aorta. Tex Heart Inst J 1995;22:162-165.[Medline]
Accepted for publication November 21, 1999.
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Abstract
Introduction
