Ann Thorac Surg 2001;71:1011-1013
© 2001 The Society of Thoracic Surgeons
Case report
Stapling of an aortic arch aneurysm
Eduardo A. Tovar, MDa,b
a Department of Cardiothoracic Surgery, St. Jude Medical Center, Fullerton, California, USA
b University of California, Irvine Medical Center, Orange, California, USA
Accepted for publication March 1, 2000.
Address reprint requests to Dr Tovar, 100 E Valencia Mesa Dr, Suite 301, Fullerton, CA 92835
e-mail: etovarmd{at}aol.com
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Abstract
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Saccular aneurysms of the aortic arch are usually managed with patch graft aortoplasty or with tube graft replacement. In either case, hypothermic circulatory arrest is necessary. The use of stapling devices has revolutionized pulmonary and gastrointestinal surgery; however, these instruments have rarely been used in aortic surgery except during thromboexclusion procedures. We present a simple and seemingly innovative stapling method that eliminates the need for circulatory arrest.
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Introduction
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The use of stapling devices has revolutionized pulmonary and gastrointestinal surgery, however, these instruments are rarely used in aortic surgery except during thromboexclusion procedures [1–3]. We encountered a high-risk patient who required coronary revascularization and repair of a saccular aneurysm of the aortic arch. A simple and seemingly innovative method to perform the operation is here presented.
A 67-year-old woman was seen in July 1997 for evaluation of increasing angina pectoris. Coronary angiography revealed severe triple-vessel disease. Comorbidities included obesity, diabetes, hypertension, moderate renal insufficiency, chronic anemia, and ischemic cardiomyopathy (ejection fraction 23%). In addition, the patient presented with a 6-cm saccular aneurysm of the aortic arch (Fig 1) absent in a computed tomogram (CT) performed 7 months earlier. Coronary revascularization was performed through a median sternotomy. The distal and proximal anastomoses were completed in the usual manner. Before discontinuation of cardiopulmonary bypass, the neck of the aneurysm was covered with bovine pericardium, the perfusion pressure was lowered, and a SGIA 60 knifeless 3.8 mm disposable stapler (Auto Suture, United States Surgical Corporation, Norwalk, CT) was fired, resulting in complete obliteration of the aneurysm. The patient recovered well and was discharged home 6 days after the operation. The patient continues to do well and remains event free at 2-year follow-up. Comparative images between her preoperative CT and one taken 2 years later demonstrate the stability of the reair (Fig 2).
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Fig 2. (A) 6-cm aneurysm of the aortic arch is shown in a computed tomogram. (B) Comparative image 2 years after surgery. Notice staple rows at the site of repair (arrow).
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Comment
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Saccular aneurysms of the aortic arch are usually managed with patch graft aortoplasty [4–6]. This method is favored over tube graft replacement as it requires a shorter hypothermic circulatory arrest. Despite its apparent technical simplicity, patch repair carries an 11.6% hospital mortality [7]. A high late-mortality rate and a high incidence of reoperation for peudoaneurysm formation with this technique have persuaded investigators to recommend it only when strict criteria are met [7]. These criteria include the presence of a small saccular aneurysm, the neck of the aneurysm should be less than one-third of the circumference of the normal aorta, and the unaffected aortic arch should be normal; otherwise, graft replacement should be performed [7]. Despite technologic advances, hypothermic circulatory arrest continues to be a challenging process that often results in severe coagulopathies and threatens the integrity of renal and neurologic systems [8].
We present a simple stapling method that obviated this process. The repair took only a few minutes and has remained stable as documented by a CT performed 2 years after the operation. Even though the neck of the aneurysm was wide, it did not pose a problem during the stapling procedure. The presence of thrombus inside the lumen of the aneurysm should be considered a relative contraindication to this approach. Potential complications of this method should include those of the standard approach such as left phrenic and recurrent laryngeal nerve injury as well as bleeding.
A Medline search failed to reveal cases in which stapling instruments have been used to obliterate saccular aneurysms, particularly of the aortic arch. The SGIA knifeless stapler delivers two double-staggered staple rows that, when bolstered with bovine pericardium, provide enough strength to produce a long-standing arterial repair. Because the aneurysm is not incised or resected, there is minimal chance for pseudoaneurysm formation. This case suggests that there is a practical application for stapling devices in the treatment of saccular aneurysms, however, further clinical evaluation is needed to confirm these findings.
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References
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Ergin M.A., O’Connor J.V., Blanche C., Griepp R.B. Use of stapling instruments in surgery for aneurysms of the aorta. Ann Thorac Surg 1983;36:161-166.[Abstract/Free Full Text]
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Odagiri S., Shimazu A., Shimokawaji M., Ishikura Y., Yoshimatsu H. Use of a new stapling instrument for permanent occlusion of the aorta in the surgical procedure for thromboexclusion. Ann Thorac Surg 1989;47:466-469.[Abstract/Free Full Text]
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Westaby S., Parry A.J., Lamont P., Grebenik C. Massive descending thoracic aneurysm in a Jehovah’s Witness: treatment by thromboexclusion. Ann Thorac Surg 1993;55:1233-1235.[Abstract/Free Full Text]
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Crawford E.S., Salch S.A., Schuessler J.S. Treatment of aneurysm of transverse aortic arch. J Thorac Cardiovasc Surg 1978;78:383-393.[Abstract]
-
Kirklin J.W., Barratt-Boyes B.G. Cardiac surgery. New York: Churchill Livingstone, 1993.
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Cooley D.A. Surgical treatment of aortic aneurysms. Philadelphia: WB Saunders, 1986.
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Okita Y., Takamoto S., Ando M., et al. Long-term results of patch repair for saccular aneurysms of the transverse aortic arch. Eur J Cardiothorac Surg 1997;11:953-956.[Abstract/Free Full Text]
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Caimmi P., Zanetti P.P., Castenetto E., Di Rosa E., Trucano G., Di Summa M. Aortic arch aneurysms: surgical results and follow-up in 56 patients. Cardiovasc Surg 1998;6:463-469.[Medline]
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Abstract
Introduction
