Ann Thorac Surg 2002;74:1244-1246
© 2002 The Society of Thoracic Surgeons
Case report
Less-invasive thoracic aortic aneurysm repair
Johji Fukada, MD, PhD*a,
Kiyofumi Morishita, MD, PhDa,
Nobuyoshi Kawaharada, MD, PhDa,
Akira Yamada, MD, PhDa,
Nobuhiro Harada, MDa,
Tomio Abe, MD, PhDa
a Department of Cardiothoracic Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
Accepted for publication May 19, 2002.
* Address reprint requests to Dr Fukada, Department of Cardiothoracic Surgery, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-ku, Sapporo 0608543 Japan
e-mail: atsfukada{at}yahoo.co.jp
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Abstract
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To minimize surgical trauma, we performed graft replacement of a descending aortic aneurysm through a minithoracotomy (12 cm) with the use of thoracoscopy and special vascular clamps. Contrast magnetic resonance angiography can be useful for preventing postoperative paraplegia by revealing the Adamkiewicz artery. The patient was satisfied with the postoperative comfort and good cosmetic result. Further refinement of the technique and instrumentation would make this technique a valuable adjunct to conventional thoracic aortic surgery.
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Introduction
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Video-assisted replacement of the thoracic descending aorta has not been performed in humans because shortening cross-clamp time would be difficult if access to the aneurysm is limited. However, this approach for aortic surgery might reduce morbidity in comparison with that following standard thoracotomy, which causes postthoracotomy pain and ventilatory compromise [1].
A 66-year-old man with cardiomyopathy was admitted to our hospital. Computed tomography revealed the presence of a sacciform aneurysm and contrast magnetic resonance angiography (cMRA) demonstrated that the Adamkiewicz artery, which was continuous with the anterior spinal artery, originated from the left ninth intercostal artery. The patient was placed in the right lateral decubitus position with a double-lumen endotracheal tube in place. The initial insertion site for introduction of the thoracoscope in the middle axillary line and the second port incision for the fan retractor at a point 5 cm anterior to the first incision were made in the fourth intercostal space (ICS) (Fig 1).
Under direct thoracoscopic visualization of the aortic aneurysm, a 5-cm minithoracotomy was made in the seventh ICS. The incision was extended up to 12 cm according to the location of the aneurysm. The third port incision for another access site of the thoracoscope was made at the fifth ICS in the anterior axillary line. The posterior surfaces of the aortic necks were dissected by the operator’s hand introduced through the minithoracotomy to avoid injuring the hemiazygos vein. Umbilical tapes were placed around the aortic necks. Femoro-femoral cardiopulmonary bypass (CPB) was started. Two special cross-clamps (9909-912-13; Scanlan International, St. Paul, MN) were introduced via the first incision and a fourth puncture wound 4 cm anterior to the edge of the minithoracotomy [2]. The aortic necks were transected after the placements of a proximal cross-clamp distal to the ninth ICS and a distal clamp. Video-assisted graft replacement of the aorta was performed with continuous sutures by conventional instruments. The CPB time was 51 minutes. The patient was ambulatory and was discharged from our hospital 12 days after the operation.
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Fig 1. Operative procedure. (A) The port incisions and the puncture wounds for introduction of thoracoscope, fan retractor, and two vascular clamps were made in the fourth, fifth, and seventh intercostal spaces. A 12-cm skin incision for thoracotomy was made in the seventh intercostal space. (B) Schema for the intrathoracic suturing using special vascular clamps introduced through the puncture wounds with assistance of thoracoscopic visualization.
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Comment
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The use of thoracoscopy in thoracic surgery has increased exponentially, because it has been shown to decrease postthoracotomy pain and lead to a quicker recovery [1, 3]. The same benefits appear to hold true with its use in vascular surgery. In descending aortic surgery, (1) the length of the aortic clamp period, (2) the inclusion of an intercostal artery critical to spinal cord blood flow in the exteriorized segment of the aorta, and (3) the completeness of spinal cord reperfusion are the risk factors of paraplegia [4], but shortening aortic clamp time and complete reconstruction of the intercostal artery would be difficult if visualization were restricted.
We have used femoro-femoral CPB for distal perfusion, but increase in CPB time can result in physical disadvantages. On the other hand, the goal of thoracoscope-assisted surgery should be to minimize the incision length while avoiding time-consuming intrathoracic suturing to maintain CPB time that is comparable to that in conventional aneurysmectomy. In order to achieve the above two antagonistic goals, good selection of candidates would be of primary importance, especially in the context of the extent of the aneurysm and the location of the intercostal artery that is the origin of the Adam-kiewicz artery. Reimplantation of intercostal arteries in the T8 to L1 region as an island flap into a vascular prosthesis is presumably impossible through a minithoracotomy. However, single reimplantation of an intercostal artery by the use of a side-arm graft can be sufficient if cMRA has demonstrated that artery as being the origin of the Adamkiewicz artery [5]. In our patient, cMRA demonstrated that the Adamkiewicz artery originated from the ninth intercostal artery, and we were able to place the proximal aortic clamp distal to the ninth ICS to maintain blood supply to that intercostal artery during cross-clamping.
We made a minithoracotomy that is of sufficient size to enable insertion of a hand to dissect the posterior surface of the aorta, direct visualization for control of backbleeding from the patent intercostal vessels, and a switch to emergency standard thoracotomy if necessary. Our main purpose for using these techniques is not minimization of the incision, but making it smaller. Occlusion of the aorta with two conventional vascular clamps through the thoracotomy itself necessitates a wider incision. Also, in the case of misplaced thoracotomy, the incision has to be made larger for adequate exposure. Therefore, the main benefits of using this technique are that it enables the thoracotomy size to be made smaller by introduction of aortic clamps through puncture wounds, and that it enables more accurate determination of the ICS to be incised by preobservation of the thoracic cavity using a thoracoscope.
In our patient, the incision was less than 12 cm. The improvements in patient comfort and cosmetic results are undeniable. Although we have performed total thoracoscopic graft replacement of the thoracic aorta in animals, the inability to perform this technique safely and reliably has precluded consideration of its application in humans. However, further refinement of the technique and instrumentation could make our technique a valuable adjunct to conventional aortic surgery and would make total thoracoscopic repair of thoracic aneurysms possible.
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References
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- Dajczman E., Gordon A., Kreisman H., Wolkove N. Long-term postthoracotomy pain. Chest 1991;99:270-274.[Medline]
- Castronuovo J.J., James K.V., Resnikoff M., McLean E.R., Edoga J. Laparoscopic-assisted abdominal aortic aneurysmectomy. J Vasc Surg 2000;32:224-233.[Medline]
- Kirby T.J., Rice T.W. Thoracoscopic lobectomy. Ann Thorac Surg 1993;56:784-786.[Abstract/Free Full Text]
- Kirklin J.W., Barratt-Boyses B.G. Thoracic aortic disease. Cardiac Surgery. New York: Churchill Livingstone, 1986:1449-1524.
- Yamada N., Okita Y., Minatoya K., et al. Preoperative demonstration of the Adamkiewicz artery by magnetic resonance angiography in patients with descending or thoracoabdominal aortic aneurysms. Eur J Cardiovasc Surg 2000;18:104-111.
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Abstract
Introduction
