Ann Thorac Surg 2004;77:2199-2200
© 2004 The Society of Thoracic Surgeons
Case report
Simplified thoracic aortic aneurysm repair
Marco Pocar, MD, PhDa*,
Pino Fundarò, MDa,
Francesco Donatelli, MDa
a Cattedra e Divisione di Cardiochirurgia, Università degli Studi di Milano e IRCCS Ospedale Maggiore, Milan, Italy
Accepted for publication June 6, 2003.
* Address reprint requests to Dr Pocar, Via Pompeo Litta, 2, 20122 Milan, Italy
e-mail: mpocar{at}milanocuore.org
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Abstract
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Descending thoracic and thoracoabdominal aortic operations still represent a challenge for the cardiovascular surgeon. In recent years, endovascular stent grafting has become a popular alternative to a conventional operation in selected patients, but is not always readily available or is technically contraindicated; also, long-term results are unknown. We describe a simplified surgical technique to secure a standard vascular prosthesis by performing a modified "elephant trunk" operation and discuss potential indications for its application.
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Introduction
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Surgical procedures on the descending thoracic or thoracoabdominal aorta are still often a challenge for the cardiovascular surgeon [1–3]. Operative mortality and the incidence of complications may be considered unacceptable in higher-risk patients. In this respect, stent grafting has gradually become an alternative to conventional open surgical procedures in selected patients [4]. We present a simplified technique to secure a standard vascular prosthesis and discuss the potential indications for its application.
A 68-year-old woman with a history of arterial hypertension presented at the Ospedale Maggiore di Milano emergency department with upper abdominal and posterior chest pain. Symptoms had started 4 to 5 days before and were described as "subacute pain." The patient was hemodynamically stable and not hypertensive on admission. A computed tomographic (CT) scan revealed mild left pleural effusion and a severely arteriosclerotic aorta with a localized saccular aneurysm at the mid-to-lower descending thoracic portion, 7 cm to 8 cm above the diaphragm. The maximal diameter and longitudinal extension of the aneurysm were 5.5 cm and 6 cm, respectively. The caliber of the remaining aorta was relatively normal. An emergency angiography excluded critical coronary disease, confirmed the anatomy of the aneurysm, and showed extensive obstructive arterial disease of the lower abdominal aorta and iliac-femoral vessels bilaterally (stenosis > 70%).
An urgent operation through a left posterolateral thoracotomy was planned because of persisting symptoms. Intraoperatively, the aneurysmal aorta was not frankly ruptured, although fibrin clots were removed from the left pleural cavity. The aortic wall was arteriosclerotic and calcific along the entire course, with a "porcelain" nature in some segments.
Because of the severity of aortic disease, the following technique was adopted. A relatively noncalcific segment of aorta, 5 cm to 10 cm proximal to the aneurysm, was selected for cross-clamping. Two aortic clamps were placed to exclude a very short segment of aorta, and partial cardiopulmonary bypass was started between the pulmonary trunk and the femoral artery. A transverse aortotomy was performed between the clamps (Fig 1A).
By temporarily releasing the distal clamp, a 24-mm tubular Dacron (DuPont, Wilmington, DE) vascular graft was inserted into the aortic lumen. The largest possible diameter was selected to obtain a hemostatic effect at the distal end of the graft while the length of the prosthesis was adjusted to exclude the aneurysmal segment. The distal clamp was then repositioned, thus clamping the aorta and the graft itself. Distal perfusion was resumed and the prosthesis was sutured intraluminally to the posterior aortic wall between the two clamps (Fig 1B). The aorta was then closed anteriorly by securing the aortotomy margins with the prosthesis. This resulting modified "elephant trunk" procedure was performed in a relatively straightforward manner (Fig 1C). Perfusion was interrupted only to insert the vascular graft.
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Fig 1. (A) A short segment of aorta between the clamps is selected for aortotomy. (B) The proximal end of a standard vascular graft is sutured intraluminally. (C) The resulting modified "elephant trunk" before the clamps are released.
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Comment
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Prosthetic vascular replacement through a left thoracotomy represents the standard treatment of a descending thoracic aortic aneurysm [1–3]. Stent grafting has become a popular alternative to a conventional operation in recent years and is particularly appealing in higher-risk populations (comorbidities, advanced age) with localized aneurysms [4]. "Open" stent grafting and similarly, "elephant trunk" operations, have also been used to treat lesions surgically in the proximal descending aorta through the aortic arch by a median sternotomy [5, 6]. However, expertise with interventional strategies may be limited or not readily available; likewise, some situations, such as concomitant severe peripheral arterial disease, may represent contraindications for endovascular techniques.
The technique described above is a reasonable compromise between a conventional operation and endovascular stenting and in our opinion, represents a relatively simple surgical solution. Also, in our particular patient, a CT scan 2 months after the operation showed complete thrombosis of the periprosthetic space (Fig 2). We have performed this operation in a single patient but consider this strategy potentially useful in patients undergoing treatment of descending thoracic aortic disease through a left thoracotomy, who present with a severely diseased and diffusely calcific aorta and for whom stent grafting is not available or contraindicated.
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Fig 2. A computed tomography scan performed 2 months after the operation shows complete thrombosis of the periprosthetic space.
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References
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- Wan I.J., Angelini G.D., Bryan A.J., Ryder I., Underwood M.J. Prevention of spinal cord ischaemia during descending thoracic and thoracoabdominal aortic surgery. Eur J Cardiothorac Surg 2001;19:203-213.[Abstract/Free Full Text]
- Halstead J.C., Baghai M., Lim E., Dunning J.J., Large S.R. A method for descending thoracic aortic replacement retaining a posterior strip bearing intercostal vessels. Ann Thorac Surg 2003;75:1660-1661.[Abstract/Free Full Text]
- Coselli J.S., Conklin L.D., LeMaire S.A. Thoracoabdominal aortic aneurysm repair: review and update of current strategies. Ann Thorac Surg 2002;74(Suppl):1881-1884.
- Mitchell R.S. Stent grafts for the thoracic aorta: a new paradigm?. Ann Thorac Surg 2002;74(Suppl):1818-1820.
- Uchida N., Ishihara H., Sakashita M., Kanou M., Sumiyoshi T. Repair of the thoracic aorta by transaortic stent grafting (open stenting). Ann Thorac Surg 2002;73:444-448.[Abstract/Free Full Text]
- Palma J.H., Almeida D.R., Carvalho A.C., Andrade J.C., Buffolo E. Surgical treatment of acute type B aortic dissection using an endoprosthesis (elephant trunk). Ann Thorac Surg 1997;63:1081-1084.[Abstract/Free Full Text]
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Abstract
Introduction
