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Ann Thorac Surg 2002;74:1292
© 2002 The Society of Thoracic Surgeons
a Division of Thoracic and Cardiovascular Surgery Missouri Baptist Medical Center St Louis, MO 63131 USA
To the Editor
We read with great interest the recent article by Beaver and Martin [1]. They report a technique that they believe offers advantages over the two-stage "elephant trunk" procedure for extensive aneurysms of the thoracic aorta. We agree with them that a single-stage procedure is an acceptable option, provided that the mortality and morbidity do not exceed those for the staged procedure.
However, we believe that the technique they have described has certain limitations that may affect short- and long-term outcomes, and that insufficient follow-up is available to conclude that it is comparable or superior to other single-stage techniques that have been reported by us and by other investigators [2–4].
Approaching the descending thoracic aorta through an incision in the posterior pericardium provides only limited exposure, and thus it would be difficult to attach a graft to the proximal descending aorta at or above the level of the left pulmonary hilus.
Of greater concern, the intercostal arteries above the level of the transected aorta remain patent, providing the potential for "endoleak." Although no leaks were demonstrated on computed tomographic studies before hospital discharge, no late computed tomographic examinations were reported. Two patients died after discharge, of unknown causes. These deaths could have been related to endoleak. Isolation of the intercostal arteries above the site of the distal aortic anastomosis occurs with this technique, and was associated with a rate of paraplegia of 14%. Although the number of patients is small, this prevalence of paraplegia for operations on the descending thoracic aorta is higher than that reported for contemporary series of second stage elephant trunk procedures [5], and for isolated descending thoracic replacements [6–8].
A further concern is the performance of the proximal anastomosis of the aortic graft to the ascending aorta, with suturing of the aortic wall to the graft in this area. If an endoleak is present or develops at a later time, there is the potential for the resulting hematoma to separate the graft from the aortic tissue surrounding the brachiocephalic arteries or where it is sutured to the aorta. This also points to the need for careful follow-up of the hospital survivors.
The mean duration of hypothermic circulatory arrest was 72 minutes, and the longest interval was 104 minutes. This duration of circulatory arrest is substantially longer than that currently accepted as "safe" (45 to 60 minutes) [9, 10], than that reported with the first stage of the elephant trunk technique [5, 9], and with the technique of performance of the arch anastomosis before the distal aortic anastomosis, which we and other researchers favor [2, 11].
The prevalence of pulmonary complications was substantial (35% of the patients required tracheostomy). Avoidance of a left thoracotomy did not reduce the prevalence of these complications when compared with other techniques in which a left thoracotomy was used [2–5, 8].
Thus, we cannot agree with the authors that "the transmediastinal approach through a standard median sternotomy will prove to be the least morbid of the single-stage techniques." A larger series of patients carefully followed with serial computed tomographic scans will be necessary to support this assumption.
References
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