Ann Thorac Surg 2004;78:725-726
© 2004 The Society of Thoracic Surgeons
How to do it
Exposure of the proximal descending thoracic aorta in the first stage of the elephant trunk procedure
Pier Paolo Zanetti, MDa*,
Paolo Loddo, MDb,
Giovanni Ciuffo, MDb,
Salvatore Lentini, MDa,
Valter Casati, MDa
a Division of Thoracic and Vascular Surgery, Policlinico di Monza, Monza, Italy
b Division of Thoracic and Vascular Surgery, G. Brotzu Hospital, Cagliari, Italy
Accepted for publication September 25, 2003.
* Address reprint requests to Dr Zanetti, Division of Thoracic and Vascular Surgery, Policlinico di Monza, via Amati 111, Monza (20052), Italy
e-mail: pp.zanetti{at}policlinicodimonza.it
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Abstract
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My colleagues and I propose a simple and reproducible technique to achieve optimal exposure and mobilization of the distal aortic arch and proximal descending thoracic aorta in the first stage of the elephant trunk procedure. The technique uses division of the ligamentum arteriosum and a series of circumferential pledgeted traction stitches on the segment of aorta selected for the distal anastomosis.
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Introduction
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One of the most crucial steps in the first stage of an elephant trunk procedure through a sternotomy approach is the achievement of a reliable distal suture line [1]. This surgical step may become an important technical challenge, especially in the presence of a prominent aortic arch aneurysm with involvement of the first segment of the descending thoracic aorta [2].
The technique my colleagues and I propose mobilizes these otherwise hard-to-reach aortic segments into the surgical field. The improved exposure allows the tailoring of a reliable, watertight distal anastomosis and an appropriate distance between this anastomosis and the left subclavian artery takeoff.
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Technique
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The heart is exposed by median sternotomy and pericardiotomy. Cardiopulmonary bypass with deep hypothermia and circulatory arrest or circulatory arrest with moderate hypothermia and selective antegrade perfusion of the epiaortic vessels is used.
A careful dissection is performed along the ascending aorta and arch. The distal aortic arch is mobilized and freed up by division of the ligamentum arteriosum. After circulatory and cardioplegic arrest, the aortic lumen is entered. A series of interrupted pledgeted stitches is placed circumferentially in the aortic segment selected for the distal anastomosis. The stitches are then passed through an invaginated tubular Dacron (DuPont, Wilmington, DE) graft positioned within the aortic lumen, and gentle traction is applied to pull up the anastomotic area medially and anteriorly into the surgical field (Fig 1).
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Fig 1. The arch and the proximal segment of the descending thoracic aorta are opened. The traction on the circumferentially placed pledgeted stitches brings the anastomotic area into the surgical field and aligns the graft with the aortic wall.
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The distal anastomosis is then easily performed withrunning 3-0 Prolene (Ethicon, Somerville, NJ; Fig 2). In the presence of an acute dissection the invaginated graft is positioned within the true lumen of the descending thoracic aorta. In chronic dissecting aneurysm we remove the intimae flap as far as possible before inserting the graft. We then evaginate the proximal segment of the graft and reimplant the epiaortic vessels (Fig 3).
The graft is cross-clamped proximal to the epiaortic vessels; cardiopulmonary bypass and rewarming are resumed by using femoral arterial inflow. The suture lines are inspected, the proximal aortic anastomosis is completed, deairing is accomplished, and the cross-clamp is removed.
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Comment
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In the first stage of the elephant trunk procedure, the distal suture line through a median sternotomy can be a challenging task when a suitable distal aortic anastomosis neck is deep in the left hemithorax, with a very limited exposure. Before the use of the described technique, we occasionally resorted to a left anterolateral thoracotomy at the fourth intercostal space to achieve surgical control of the proximal descending thoracic aorta and safely perform the distal suture line [3].
The technique we propose is inexpensive, reliable, and reproducible. It allows an excellent exposure and distal anastomosis in a segment of the descending thoracic aorta that could not otherwise be reached through a median sternotomy. We applied this technique in 10 patients and were consistently able to achieve an excellent exposure and watertight anastomosis on the first segment of the descending thoracic aorta.
In addition, this technique affords an adequate distance between the distal aortic and the epiaortic vessel suture lines. This can help avoid, in some cases, the sacrifice of the left subclavian artery [4] and the difficult hemostasis caused by the proximity and encroachment of these 2 suture lines on each other.
In conclusion, we suggest the use of this technique in the first stage of the elephant trunk procedure, particularly in the presence of aneurysmal dilatation of the distal arch and proximal descending thoracic aorta. The excellent exposure, a safe distal anastomosis, and its adequate distance from the epiaortic vessels are the most important features of this technique, with the added benefit of avoiding unnecessary left thoracotomy.
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References
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- Borst H.G., Walterbusch G., Schaps D. Extensive aortic replacement using "elephant trunk" prosthesis. J Thorac Cardiovasc Surg 1983;31:37-40.
- Ando M., Nakajima N., Adachi S., Nakaya M., Kawashima Y. Simultaneous graft replacement of the ascending aorta and total aortic arch for type A aortic dissection. Ann Thorac Surg 1994;57:669-676.[Abstract/Free Full Text]
- Borst H.G., Frank G., Schaps D. Treatment of extensive aortic aneurysm by a new multistage approach. J Thorac Cardiovasc Surg 1988;95:11-13.[Abstract]
- Svensson L.G. Rationale and technique for replacement of the ascending aorta, arch, and distal aorta using a modified elephant trunk procedure. J Card Surg 1992;7:301-312.[Medline]
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Abstract
Introduction
