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Ann Thorac Surg 2002;74:1293
© 2002 The Society of Thoracic Surgeons
a Division of Thoracic and Cardiovascular Surgery University of Florida College of Medicine Gainesville, FL 32610 USA
To the Editor
Dr Kouchoukos and colleagues had several concerns regarding our article [1]. We would like to address each of them in turn.
We believe the transpericardial approach is manageable for an experienced aortic surgeon; hemostasis at the distal suture line can be complimented with the use of "bioglue" (Cryolife), which is now Food and Drug Administration approved.
Although we have early evidence that endoleaks are not a problem, only longer term (on-going) follow-up, as with stent grafts, will ultimately answer this question. We believe our approach is similar to the combined aortic arch repair with distal stenting ("open stenting") as described by Kato [2] and Uchida [3] and their colleagues; with the advantage that our distal anastomosis is sutured to better prevent endoleaks and avoids the need for a stent graft.
Since the initial report 6 additional patients have undergone the procedure without paraplegia, which lowers the overall incidence to 10%. One of 2 patients had previously undergone an infrarenal aortic operation, which was found to be a risk factor in a large series of thoracic stent grafts [4]. In an effort to reduce the neurologic morbidity we now place a spinal drain the evening before operation (as the patients are completely heparinized at the time of operation). We do note in the series by Dr Kouchoukos and associates that "patent intercostal arteries above the level of the sixth intercostal space are ligated" [5], which is approximately the level of our transpericardial approach.
We still favor the anastomosis technique proximal to the innominate artery as described by Kusuhara and co-workers [6], although we do test the arch vessel anastomosis before resuming bypass. Circulatory arrest times are admittedly longer as acknowledged in the discussion; however, after the distal anastomosis has been completed we now perfuse the visceral vessels and lower extremities with a balloon tip cannula placed in the descending graft.
As for the tracheostomy and pulmonary complications: we do favor early tracheostomy for chronically ventilated patients with multiple comorbidities. The emphasis on a single stage repair is not simply to avoid a thoracotomy but to assure that patients receive complete treatment for all of their aneurysmal disease. Dr Safi from the University of Texas recently published his experience with the staged elephant trunk procedure in 117 patients [7]. Thirty-day stage I mortality was 5.1% and stage II mortality was 6.2%. However, 3 of 4 patients died in the interval from rupture and 43 (37%) patients never returned for the second stage. A single stage procedure as described by Kouchoukos, Kato, Uchida, and their colleagues or ourselves completely corrects the patients’ aneurysmal disease at the time of the initial operation.
We appreciate the comments of Dr Kouchoukos and associates and offer "The Single-Stage Transmediastinal Approach" as an additional tool in the aortic surgeon’s armamentarium.
References
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