Ann Thorac Surg 2003;76:1203-1207
© 2003 The Society of Thoracic Surgeons
Original article: cardiovascular
Late reoperation for proximal aortic and arch complications after previous composite graft replacement in marfan patients
Teruhisa Kazui, MD, PhDa*,
Katsushi Yamashita, MD, PhDa,
Hitoshi Terada, MD, PhDa,
Naoki Washiyama, MD, PhDa,
Takayasu Suzuki, MDa,
Kazuhiro Ohkura, MDa,
Kazuchika Suzuki, MDa
a First Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
Accepted for publication April 18, 2003.
* Address reprint requests to Dr Kazui, First Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, 431-3192, Japan.
e-mail: tkazui{at}hama-med.ac.jp
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Abstract
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BACKGROUND: Marfan patients who received composite graft replacement for proximal aortic disease frequently require late reoperation. The initial surgical technique for this lesion remains controversial.
METHODS: Fourteen Marfan patients who received composite graft replacement for annuloaortic ectasia with or without aortic dissection required late reoperation thorough re-median sternotomy. The techniques used for an initial composite graft replacement were the original Bentall procedure in 11 patients, the Cabrol procedure in 2, and coronary button technique in 1. Reoperation was indicated for prosthesis-related complications in 10 patients, distal aortic lesion in 13, or for both lesions in 8. Reoperations were performed, on average, 8.4 years after an initial operation. Reoperative procedures included re-composite graft replacement in 1 patient, total arch replacement in 5, and re-composite graft replacement with total arch replacement in 8.
RESULTS: There were two in-hospital deaths (14.3%). Although pseudoaneurysms of the coronary artery or distal aorta occurred in the original Bentall or Cabrol procedures, true aneurysms of the coronary artery were noted even in the coronary button technique. Six patients required a total of eight subsequent descending or thoracoabdominal aortic replacements for an aneurysmal formation of a distal false lumen.
CONCLUSIONS: The coronary button technique, with a small side hole for coronary anastomosis, is the procedure of choice for annuloaortic ectasia because it reduces the risk of coronary artery–related complications. Concomitant total arch replacement may be recommended for annuloaortic ectasia with DeBakey type I aortic dissection in selected patients to avoid the risk of reoperation on the aortic arch.
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Introduction
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A major cardiovascular manifestation in a Marfan patient is the proximal ascending aortic disease characteristic of annuloaortic ectasia. It is frequently complicated by an aortic dissection when the size of the aneurysm exceeds 5 cm in diameter. Remarkable progress in the surgical treatment of annuloaortic ectasia has been made ever since Bentall advocated composite graft replacement of the ascending aorta and the aortic valve in 1968 [1], followed by a modified coronary anastomotic technique, including the Cabrol procedure [2], the Piehler procedure [3] and a coronary button technique (Carrel procedure) [4, 5]. Increasing experience with the long-term results of a composite graft replacement, however, suggests that reoperation through resternotomy is required in a certain number of patients for various reasons. The purpose of this study is to retrospectively evaluate initial surgical techniques for annuloaortic ectasia in Marfan patients undergoing a late reoperation.
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Material and methods
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The subjects of the present study included 14 typical Marfan patients who received initial composite graft replacements for annuloaortic ectasia with or without aortic dissection, and who required reoperation through remedian sternotomy in the late postoperative period between 1991 and 2001. The age of the patients at the initial operation ranged from 26 to 41 years, with an average of 32 years, and included 11 men and 3 women. Proximal ascending aortic lesions at the initial operation included isolated annuloaortic ectasia in 2 patients and annuloaortic ectasia with a DeBakey type I aortic dissection in 12 (9 acute, 3 chronic) (Table 1).
As an initial surgical procedure, composite graft replacements were performed in all patients: the original Bentall procedure in 11 patients, Cabrol in 2, and a coronary button technique in 1. Eight out of 14 patients (57%) received an initial composite graft replacement (five Bentall, two Cabrol, one coronary button technique) at another institution. Nine patients were operated on for acute type A dissection on an emergency basis, and 5 electively, for either annuloaortic ectasia or a chronic type A dissection. The time interval between the initial and second operation ranged from 0.7 to 18 years, with an average of 8.4 years, and exceeded 10 years in 8 out of 14 patients (57%).
Indications for a reoperation included prosthesis-related complications in 10 patients, distal aortic lesion in 13, and both lesions in 8. Among the prosthesis-related complications, there were four cases of pseudoaneurysm of the coronary artery anastomosis (three Bentall, one Cabrol) and four cases of true aneurysm of the coronary artery anastomosis (three Bentall and one coronary button technique) (Figs 1–4).
One patient, who received the Cabrol
procedure, developed a pseudoaneurysm of the left
coronary artery anastomosis and a left anterior myocardial
ischemia due to a Cabrol limb stenosis secondary to limb kinking and a pannus formation of the graft. In addition to coronary artery–related complications, there was one case of candida endocarditis (Bentall) and one case of pseudoaneurysm of the distal aortic anastomosis (Bentall). As for distal aortic lesions, there were 13 cases of persistent false lumen of the aortic arch associated with an aneurysmal formation of the descending or thoracoabdominal aorta (10 Bentall, two Cabrol, one coronary button technique). One of them presented with cerebral ischemia due to cerebral malperfusion secondary to the extension of the dissection to arch vessels.
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Fig 1. Preoperative aortogram (left) and drawing (right) showing true aneurysm at the site of both coronary anastomoses in patient who received original Bentall procedure for annuloaortic ectasia with acute aortic dissection 9 years ago.
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Fig 2. Intraoperative photograph of the patient in Figure 1 showing true aneurysm of coronary ostia associated with a large side hole of the graft.
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Fig 3. Preoperative aortogram (left) and drawing (right) showing true aneurysm at the site of both coronary anastomoses, persistent false lumen of aortic arch, and aneurysmal formation of false lumen of the descending aorta in a patient who received the coronary button technique for annuloaortic ectasia with acute aortic dissection 2 years ago.
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Fig 4. Preoperative aortogram (left) and drawing (right) of true aneurysm at left coronary anastomosis, persistent false lumen of aortic arch, and redissection of descending aorta featuring triple lumen in patient who received original Bentall procedure for annuloaortic ectasia with chronic dissection 12 years ago.
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Eight patients were reoperated on for both prostesis-related complications and distal aortic lesions. All reoperations were performed on an elective basis. Reoperative procedures included re-composite graft replacement in 1 patient (Piehler), total arch replacement using the separated graft technique in 5 [6], and re–composite graft replacement with total arch replacement in 8 (one Piehler, one Cabrol, six coronary button technique). Using a coronary button technique, we made sure the size of the hole in the graft was 7 to 8 mm to fit the size of the coronary artery, whereas a coronary anastomosis was performed using a running 5-0 monofilament suture without any Teflon felt strips. At reoperation, a mechanical valve was implanted in all patients. The elephant trunk technique was concomitantly performed in 5 patients who received a total arch replacement in a subsequent operation on the descending or thoracoabdominal aorta. Other concomitant procedures included mitral valve replacement in 1 patient and descending aortic graft replacement, performed through an opening in the left parietal pleura, in 1 patient for impending rupture of the aneurysm of the descending aorta.
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Results
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The surgical results of reoperation are summarized in Table 1. Two patients (14.3%), who underwent a re-composite graft replacement and total arch replacement early in the series, died in hospital; One patient died of low cardiac output syndrome, and the other died suddenly of acute myocardial infarction, due to the occlusion of a Cabrol right limb graft, 20 days after the operation. Pseudoaneurysm of the coronary artery was noted in three cases of the original Bentall procedure, and one case of the Cabrol procedure, and a pseudoaneurysm of the distal aorta in one case of the original Bentall procedure. On the other hand, true aneurysm of the coronary artery was noted in three cases of the original Bentall procedure and one case of the coronary button technique. The proximal coronary artery was aneurysmal in shape (Fig 1), and the diameter of the side hole made in the composite graft seemed remarkably bigger than that of the respective coronary arteries (Fig 2).
Histopathology of a true aneurysm of the coronary artery showed the same cystic medial necrosis as the aortic wall, and the three layers of the aortic wall were maintained throughout. Twelve patients survived the operation and were discharged from the hospital. One patient, who was reoperated on for endocarditis, died of brain stroke due to verruca embolization 1 year later. Six patients underwent a subsequent eight descending or thoracoabdominal aortic graft replacements for an aneurysmal dilation of the distal false lumen in the late postoperative period, and 1 patient died of graft infection after a third operation. Four patients eventually underwent total aortic replacement extending from the aortic annulus to the abdominal aortic bifurcation.
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Comment
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Aortic root replacement with a composite valve graft has become the established procedure for annuloaortic ectasia in Marfan patients [7]. However, long-term results of the original Bentall procedure have since been made available, and cases in which reoperation is required due to various complications have been reported [8–12]. The causes of late reoperations include pseudoaneurysms of the distal aortic anastomosis or coronary artery anastomosis, prosthetic valve endocarditis, thrombosed valve, and paravalvular leak. Especially whenever the graft inclusion technique (in which the graft is wrapped by the aneurysmal wall) was used in the original Bentall operation, pseudoaneurysms at the anastomotic sites of the coronary artery or the aorta are known to have occurred frequently [9, 11], and this was also confirmed in our present study.
To avoid this pseudoaneurysm complication, we have switched to a graft exclusion technique, in which the aorta and the coronary arteries are transected completely and sutured to the graft using full-thickness bites, and since then, have not experienced any more complications of this kind. On the other hand, complications of true aneurysm at the site of coronary anastomosis, after an original or modified Bentall procedure, have been extremely rare [13].
Savunen and associates reported that a slight-to-moderate dilation of one or both coronary origins was observed on the follow-up angiogram in 9 out of 22 Marfan patients who had had the coronary button technique [14].
The cause of true aneurysm at the coronary anastomosis is unknown. Because the Marfan syndrome is a systemic and progressive disorder caused by a defect in microfibrils, the redundant aortic wall around the coronary artery may have developed aneurysmal changes in the late postoperative period. Therefore, to reduce the risk of this complication, the size of the side hole made in the graft must be reduced to fit the diameter of the coronary artery [15, 16], and a suture should be placed inside the origin of the coronary artery in coronary anastomosis, so that a residual aortic wall can be eliminated. The indications for a surgery for coronary aneurysm in our series included the appearance of angina pectoris, progressive enlargement of the aneurysm, and the occurrence of aneurysm in patients requiring distal aortic repair.
Coronary reconstruction at reoperation can be performed safely by the interposition of an artificial graft between the coronary artery and the side hole of the graft, especially when the dissection extends to the coronary artery and local repair is difficult, or when the coronary artery is not easily detached from the surrounding tissues and its direct anastomosis with the side hole of its graft is anticipated to produce excessive tension. The Cabrol [2] and Piehler methods [3] are applied to coronary reconstruction using an artificial graft. Because we experienced one graft limb occlusion of the coronary artery after the Cabrol method, we prefer the Piehler one. However, the coronary artery can be usually detached from the surrounding tissue even in the case of reoperation, and therefore, the coronary button technique is considered to be advantageous, allowing a full-thickness bite at the coronary anastomosis, and leaving no wall of sinuses of Valsalva.
Apart from a reoperation for previous composite graft replacement–related complications, reoperation on the distal aorta is frequently required in patients who had had aortic dissection at the time of an initial composite graft replacement for an aneurysmal formation of a distal false lumen in the long-term [16–18]. Eleven patients who had complications of aortic dissection [8 acute, 3 chronic) required reoperation on the aortic arch through remedian sternotomy for a persistent false lumen of the aortic arch, and 2 patients died in our series. Crawford and associates reported that a previous proximal aortic operation was a risk factor for operative mortality during aortic arch repair [19].
Although a simultaneous total arch replacement is recommended in the case of annuloaortic ectasia with DeBakey type I aortic dissection, that is, an associated arch dissection, the question still remains whether such an aggressive approach might increase the risk of early mortality in the critically ill patient with an acute aortic dissection. We have previously reported that simultaneous total arch replacements could be performed with an acceptable risk if the patient does not display any risk factors, such as profound shock or renal/mesenteric ischemia [20]. We also pointed out that nonresection of the intimal tear and younger age (mostly Marfan patients) were independent predictors for distal aortic reoperation [21]. Therefore, it is recommended that young Marfan patients without serious dissection-related complications, such as profound shock or renal/mesenteric ischemia, have a simultaneous total arch replacement. Moreover, total arch replacements with the elephant trunk technique could not only reduce the risk of leakage through the needle hole at the site of a distal graft anastomosis in the case of acute dissection, but also facilitate a reoperation on the distal thoracoabdominal aorta through a left thoracotomy in the case of a chronic dissection.
As a reconstructive procedure of the aortic arch in patients with Marfan syndrome, an en bloc technique, in which arch vessels are anastomozed to the side hole of the graft in an island fashion, may lead to an aneurysmal formation of the aortic arch around the arch vessels in the late postoperative period. Therefore, to avoid this complication, a separated graft technique, using an aortic arch branched graft, should be used [6].
It is a limitation of this study that it is both retrospective and noncomparative, as well the fact that it includes a rather small number of patients. However, it provides a certain amount of information on how to reduce the incidences of a late reoperation in Marfan patients.
In summary, an appropriate surgical composite graft replacement technique for a proximal aortic disease, and a simultaneous aortic arch repair in the presence of an aortic dissection, could be recommended for reducing the risk of reoperation through remedian sternotomy in the patient with Marfan syndrome.
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References
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Abstract
Introduction
