Ann Thorac Surg 2002;73:1332-1334
© 2002 The Society of Thoracic Surgeons
How to do it
A method of repair for asymmetric aneurysmal dilatation of the ascending aorta
Leonid Sternik, MDa,
Kenton J. Zehr, MD*a,
Hartzell V. Schaff, MDa
a Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
Accepted for publication November 3, 2001.
* Address reprint requests to Dr Zehr, Division of Cardiovascular Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905 USA
e-mail: zehr.kenton{at}mayo.edu
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Abstract
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The repair technique for an ascending aortic aneurysm depends on the portion of the aorta involved. An aneurysm in which the geometry of the sinotubular junction and the distal ascending aorta is preserved has classically been treated with resection and replacement with tube graft. We report an alternate method of resection of asymmetric aneurysmal dilatation of the ascending aorta with primary end-to-end anastomosis and our results of this approach with 14 patients. This method allows for complete resection of the aneurysm and tension-free anastomosis; it requires only one suture line and theoretically reduces the risk of bleeding. The endothelial surface of the aorta is preserved without an interposed synthetic graft. This method can be performed safely and the repair is durable at intermediate-term follow-up.
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Introduction
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The type of repair for an ascending aortic aneurysm depends on the portion of the ascending aorta involved. If the dilatation of the aorta involves the sinotubular junction and sinuses, or if there is intrinsic disease in the aortic wall, then surgical treatment requires replacement of aortic tissues from the annulus to the arch. If there is coexisting aortic valve pathology, then replacement with a composite valve conduit graft, the modified Bentall procedure, is indicated [1–4]. In contrast, many patients present with near normal sinuses of Valsalva and sinotubular junctions with the asymmetric aneurysmal dilatation involving the ascending aorta to the base of the innominate artery. This type of dilatation is often associated with a bicuspid aortic valve. Classically these aneurysmal aortas have been treated with replacement of the mid-ascending aorta with a tube graft [1–3, 5] or longitudinal tailoring by plication or wedge resection [3, 6]. We report a method of dealing with asymmetric ascending aortic aneurysms with preserved geometry of the sinotubular junction and distal ascending aorta.
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Technique
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A median sternotomy was the operative approach. The aortic cannula was placed in the proximal arch in all patients. Cardiopulmonary bypass was established with normothermia or mild hypothermia. The aorta was cross-clamped distal to the aneurysm at the base of the innominate artery. The entire aneurysmal portion of the ascending aorta was resected in a wedge shaped manner (Figs 1 and 2). All primary anastomoses were end-to-end and tension free. In several patients we needed to perform some mobilization of the aortic arch by dissection of the great vessel to pericardial attachments adjacent to the innominate artery and aortic arch. A continuous 4-0 polypropylene suture was used for an anastomosis. In 6 patients the suture line was reinforced with a felt strip.
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Fig 1. Resected aortic specimen. Note the wedge-shaped resection measuring 5 cm on the greater curvature and 1.5 cm on the lesser curvature.
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Fig 2. (A) The appearance of the asymmetrically dilated aneurysmal ascending aorta. (B) The appearance of the ascending aorta after wedge-shaped resection and primary end-to-end anastomosis.
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Results
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Fourteen patients had operations by this method from December 1997 to June 2000. All patients had aneurysmal dilatation of 4.6 cm to 6.0 cm of the ascending aorta with a normal or near-normal sized sinotubular junction and distal ascending aorta at the base of the innominate artery. The median age of these patients was 64 years (range, 40 to 80 years). Eleven patients also underwent aortic valve replacement. Twelve patients had a bicuspid aortic valve.
All patients had an uneventful operation. In 2 patients with isolated resection of aneurysm, the cardiopulmonary bypass times were 20 and 23 minutes and the cross-clamp times were 13 and 19 minutes, respectively.
Verhoeff’s-van Gieson’s stain of the resected aortic wall did not find pathology in 12 patients. In one patient lymphoplasmacytic aortitis was found, and cystic medial degeneration was discovered in another.
There was no perioperative mortality, and there were no significant complications. Eight patients received no blood products. There was one late death caused by intracranial hemorrhage. The remaining 13 patients were in New York Heart Association functional classes I and II and their follow-up echocardiograms or computed tomographic scans revealed a normal appearing ascending aorta and native or prosthetic aortic valve. The longest follow-ups were at 18 months (2 patients), 17 months (1 patient), and 13 months (1 patient); the remaining patients had a follow-up of less than 1 year.
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Comment
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An aneurysm or dilatation of the ascending aorta is frequently encountered in conjunction with aortic valve pathology or it can be an isolated problem. Various methods of surgical repair have been suggested depending upon the portion of the aortic root or ascending aorta, which is involved with the dilatation. Our method addresses the management of an asymmetrically aneurysmal ascending aorta with preserved geometry of the sino-tubular junction and the distal ascending aorta. The classic surgical solution for this pathology has been tube graft replacement [1, 2]. A more conservative approach of tailoring the ascending aorta has been suggested [3, 6]. There are several problems related to both of these methods. Graft replacement of the ascending aorta requires two anastomoses. This contributes to an increase in cross-clamp times and an incremental increased risk of bleeding from the suture lines. An increased incidence of embolic events related to this large surface without endothelial coverage in the ascending aorta has been reported [2–6]. Tailoring of the ascending aorta is less time consuming in comparison with graft replacement. This is an incremental improvement in decreasing comorbidity related to a longer cardiopulmonary bypass time in elderly patients with combined pathology of the aortic valve, ascending aorta, and coronary artery disease. In addition, there is the advantage of the preservation of endothelial coverage of the ascending aorta. The drawback of tailoring the ascending aorta is that the patients are left with thin and potentially diseased aortic walls. This can result in recurrence of aneurysmal dilatation and rupture of the aorta after aortoplasty.
This new method of resection and end-to-end anastomosis is an aggressive surgical approach to a complete resection of the aneurysmal dilatation. This approach has the advantage to less radical methods. The surgical procedure is simpler and requires only one suture line, which potentially reduces the risk of bleeding. The endothelial surface of the aorta is preserved without an interposed synthetic graft. All of our patients received a secure anastomosis without undue tension. This procedure can be performed with few postoperative complications.
The mean follow-up was 6 months. It is difficult to discuss long-term advantages and disadvantages with a high degree of confidence. However it does seem clear that this method is applicable and effective in selected patients.
In conclusion, we recommend resection and primary end-to-end anastomosis as an alternative surgical approach for patients with asymmetric aneurysmal dilatation of the ascending aorta with preserved sinotubular junction and distal ascending aorta. This method allows radical resection of the aneurysm and can be performed with ease, and it is faster than graft replacement of the ascending aorta. This technique preserves the endothelial lining of the aorta, diminishes the potential for bleeding, and eliminates the need for synthetic graft material.
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References
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Abstract
Introduction
