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Ann Thorac Surg 2002;74:2226-2227
© 2002 The Society of Thoracic Surgeons
a Divisione e Cattedra di Cardiochirurgia,IRCCS Ospedale Maggiore di Milano,Università degli Studi di Milano,Via Francesco Sforza, 35,20122 Milano, Italy
e-mail: mpocar{at}milanocuore.org
To the Editor:
We read with great interest the recent article by Beaver and Martin concerning one-stage replacement of the entire thoracic aorta through a median sternotomy [1]. The results are encouraging compared with staged operation, especially considering the difficulties encountered in calling back patients for the second procedure on the descending aorta after a successful first step. However, we would like to focus on some aspects of the technique.
Since September 2000, we have applied a similar philosophy to patients with indications for operation on intrapericardial structures and descending thoracic aorta in three instances: annuloaortic ectasia associated with chronic type B dissection in 1 patient, and coronary artery disease associated with descending aortic aneurysm in 2 (mean age, 72 ± 6 years). We have not performed the distal anastomosis of the graft, but simply fashioned the prosthesis as a long "elephant trunk" through the open aortic arch, as described for acute type B dissections [2]. The difference from previous reports is that a much longer prothesis (18 to 20 cm) was implanted in the descending aorta. The diameter of the Dacron graft was 24 mm in two cases and 26 mm in one. No patient died or developed paraplegia/stroke. Duration of circulatory arrest was 39 ± 11 minutes. Retrograde superior caval perfusion was used during circulatory arrest. Intensive care unit and hospital stays were 4.7 ± 0.6 and 13.3 ± 2.1 days, respectively. Mean follow-up is 8.7 ± 4.7 months. The idea of pulling down the tubular prosthesis by securing it to a guidewire is brilliant, but our feeling is that completion of the distal anastomosis is potentially useless and certainly time-consuming. In the series described by Beaver and Martin, circulatory arrest time averaged 72 minutes (with a minimum of 56 minutes) while the distal anastomosis was made and supraaortic trunks were reimplanted. Probably because retrograde cerebral perfusion was used, a surprisingly low incidence of cerebral complications occurred (7%). However, longer circulatory arrest and bypass times may have contributed significantly to mortality (14%) and morbidity rates (paraplegia, 14%; tracheostomy, 36%; renal failure, 28%; hospital stay, 32 ± 22 days). Also, total exclusion of the periprosthetic space may contribute to spinal malperfusion.
We agree with Beaver and Martin that a single-stage operation is advisable for extensive aneurysmal disease. We also feel that in case of diffuse arterial disease and, often, associated advanced age and impaired multiorgan function, extensive thoracotomy is less well tolerated than a median sternotomy despite the need for circulatory arrest. We have, therefore, applied a similar concept for combined cardiac and descending aortic disease. We are, however, concerned with problems related to prolonged hypothermic circulatory arrest (especially in this patient population) as recently reviewed in The Annals [3]. A long "elephant trunk" is our first-choice in these patients.
References
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