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Ann Thorac Surg 2005;79:796-800
© 2005 The Society of Thoracic Surgeons

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Original article: Cardiovascular

Long-Term Integrity of Teflon Felt-Supported Suture Lines in Aortic Surgery

^a Department of Cardiothoracic Surgery, New York, NY
^b Department of Biomathematics, Mount Sinai School of Medicine/New York University, New York, New York

Accepted for publication August 13, 2004.

^* Address reprint requests to Dr Strauch, Friedrich-Schiller-University of Jena, Department of Cardiothoracic and Vascular Surgery, Erlanger Allee 101, 07747 Jena, Germany (E-mail: ju.strauch{at}gmx.de).

	Abstract

Top Abstract Introduction Material and Methods Results Comment References

 
BACKGROUND: Although the ultimate success of aortic operations depends upon the integrity of graft-to-aorta anastomoses, little is known about different techniques used to assure their longevity. We report the incidence of reoperation for suture line disruptions arising from anastomoses using reinforcement with Teflon felt.

METHODS: Since 1987, 1475 patients underwent 2281 anastomoses in the thoracic aorta (mean 1.55/anastomoses per patient). All patients were followed with at least yearly computed tomographic scans, for a total follow-up of 6483.8 patient-years. Those requiring reoperation were reviewed retrospectively for evidence of suture line disruption.

RESULTS: Only 34 patients, with a mean age of 55.1 years old (range 26–85 years old) underwent reoperation for suture-line disruptions following vascular graft-to-aorta anastomosis using Teflon felt. The previous operation was a Bentall procedure in 15 (44%); ascending aorta replacement in 9 (26%); total arch replacement in 6 (18%); descending aorta replacement in 2 (6%); thoracoabdominal repair in 1 (3%); and sinus of Valsalva repair in 1 (3%). The incidence of suture line disruption was 0.0052 per patient-year, and 0.0034 per anastomosis-year. The mean interval between operations was 55.9 months (range 4–180 months). In 21%, the pseudoaneurysm originated from the proximal anastomosis; in 71% from the distal anastomosis; in 3% from both; in 3% from the innominate artery; and in 3% from a sinus of Valsalva repair. In only 1 patient was there evidence of infection. Reoperation involved ascending aorta replacement in 11 patients, and total arch replacement in 13 patients. Adverse outcome, such as hospital death or permanent stroke, occurred in 8% (3 patients).

CONCLUSIONS: Use of Teflon felt to support aortic suture lines yields a very low incidence of suture line disruptions: 1 per 191 patient-years, or 1 per 296 anastomosis-years. Teflon felt reinforcement provides a secure, long-lasting graft-to-aorta anastomosis with minimal risk of infection.

	Introduction

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Recent improvements in surgical and neuroprotective techniques, as well as in perioperative care, have resulted in a low hospital mortality and better long-term outcome for patients with aneurysmal disease of the thoracic aorta. As a consequence, the number of patients at risk for development of late complications after reconstructive surgery on the thoracic aorta is increasing [1]. The routine use of echocardiography and computed tomography in the evaluation of patients after operations on the thoracic aorta has identified abnormalities in asymptomatic or minimally symptomatic patients that may require reoperation for a variety of indications [2, 3]. Suture-line disruptions are among the late complications that can cause substantial mortality and morbidity even years after primary repair of aortic lesions.

The incidence of false aneurysms or dissections originating from suture lines between grafts and the aorta is low, but we have seen a number over the past years, usually in patients in whom Teflon (DuPont Pharmaceuticals, Wilmington, DE) felt was not used to reinforce the suture line. Suture line disruption is a life-threatening complication after thoracic aortic surgery, requiring reoperation in all cases. Even in hemodynamically stable situations in which the false aneurysm does not appear to be expanding, there is no doubt that reoperation will become necessary. But although the ultimate success of aortic operations depends upon the integrity of graft-to-aorta anastomoses, surprisingly little is known about the different surgical techniques used to assure their longevity. Some information is available for the occurrence of a false aneurysm after surgical repair of acute aortic dissection: the incidence is said to be 2% to 3% [4–6, 5, 6].

The aim of this study was to ascertain the incidence of late anastomotic disruptions occurring in suture lines reinforced with Teflon felt, and the outcome of patients in whom this complication prompted reoperation.

	Material and Methods

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Patients
From June 1987 to July 2002, 1475 patients underwent operations involving the thoracic aorta. The median age was 64 years old (range 8 to 89 years old). For other clinical characteristics see Table 1. Overall, these patients had 2281 anastomoses in the thoracic aorta, with a mean of 1.55 anastomoses per patient. All aortic anastomoses were reinforced with a strip of Teflon felt. All patients were followed with at least yearly compute tomographic (CT) scans, for a total follow-up of 6483.8 patient-years. Patients who died or were lost to follow-up were included only until the date of the latest CT scan that showed intact suture lines. The follow-up analysis had the following characteristics: 88 patients were lost to follow-up, after a mean interval of 4.6 ± 3.1 years; 227 patients died during follow-up, after a mean 2.7 ± 3.1 years. The mean follow-up interval was 6.2 years.

Surgical Technique
All aortic anastomoses were performed using a standardized technique. Prolene (3-0) was used in the vast majority; a few patients had anastomosis performed with 4-0 Prolene. The back wall of the anastomosis was carried out open, with a continuous suture passing through the graft, the strip of Teflon felt, and the aorta (Fig 1A). The graft was then positioned carefully inside the aorta and the Teflon felt strip outside, and the suture line was tightened with a nerve hook (Fig 1B). The anterior portion of the anastomosis was then performed either open or closed, with particular attention to positioning the graft within the aorta, and placing the Teflon felt outside (Figs 1C and 1D). Thus the suture material compresses the aortic wall between the Teflon felt and the graft material, and the sutures per se do not pull on the aortic wall.

View larger version (79K): [in this window] [in a new window]   Fig 1. (A) The back wall of the anastomosis is performed open, with the sutures passing from the Dacron graft to the Teflon felt and then to the wall of the aorta. The first stitch is taken inside the graft. (B) The Teflon felt strip is then carefully positioned outside the aorta; the graft is invaginated within the aorta, and the back suture line is tightened with a nerve hook. (C) The second needle, on the other suture end, is passed through the aorta and the Teflon felt, and the suture line is continued in either an open or closed fashion along the front wall. Care is taken to place the graft within the aorta and to position the Teflon felt carefully on the outside. (D) The completed anastomosis. The most important aspect of the anastomosis is that the suture does not pull directly on aortic tissue. In essence, the end of the aorta is clamped between the graft and the external Teflon felt by the running sutures. This not only reduces needle hole bleeding at the time of the anastomosis, but also prevents progressive erosion of the suture through the aortic wall as stress is applied to the suture line by the pulsating aortic pressure. The snugly fitted Teflon felt also heals securely to the aorta, as does the graft on the inside, and it is possible that the cuff of Teflon felt buffers the transition between the relatively noncompliant vascular graft and the variably compliant aorta.

	Results

Top Abstract Introduction Material and Methods Results Comment References

 
During the interval under scrutiny, 34 patients, with a mean age of 55.1 years old (range 26 to 85 years old) returned to our institution and underwent reoperation for suture line disruptions following vascular graft-to-aorta anastomosis using Teflon felt. Eight patients (24%) were female and 26 (76%) were male. Twenty-four patients (71%) had been diagnosed as having dissection, 6 patients (18%) had the etiology of an atherosclerotic or degenerative aneurysm, 2 (9%) suffered from Marfan's Syndrome at the time of initial surgical intervention, and the remaining 2 (6%) had miscellaneous lesions. Eighteen patients (51%) had a history of hypertension. A mean number of 1.73 (range 1 to 4) anastomoses using Teflon felt had been carried out in these patients. The initial operation was a Bentall procedure in 15 (44%), ascending aorta replacement in 9 (26%), total arch replacement in 6 (18%), descending aorta replacement in 2 (6%), thoracoabdominal repair in 1 (3%), and sinus of Valsalva repair in 1 patient (3%). All previous operations were done at our institution. No patient had had more than one previous operation.

The incidence of suture line disruption was 0.0052 per patient-year, and 0.0034 per anastomosis-year. The average time interval between the operations was 55.9 ± 51.2 months (range 4 to 180 months). At the time of presentation, the pseudoaneurysm or dissection originated in 15% from the proximal ascending aortic anastomosis; in 53% from the distal ascending anastomosis; in 3% from both anastomoses in the ascending aortic part; in 15% from the proximal descending aortic anastomosis; and in 6% from the distal descending aortic anastomosis. In 3% of the patients the suture-line disruption was from a former Teflon felt-supported sinus of Valsalva repair and in 3% from the anastomosis to the innominate artery. In only 1 patient was there evidence of infection. In 12 patients (35%), the suture-line disruption caused a localized pseudoaneurysm; in 22 patients (65%), there was a dissection originating from the suture line.

The second operation for pseudoaneurysm repair was done in 2 patients (6%) emergently, in 13 (38%) urgently, and in 19 patients (66%) as an elective procedure. The 2 procedures done under emergency conditions and the 13 urgently performed operations were exclusively done for the newly detected dissections originating from the suture line. The remaining 7 patients with dissections were done under elective circumstances, because the localized dissection was inadequate to detect preoperatively and just confirmed by the intraoperative findings. Reoperation involved ascending aortic or Bentall replacement in 11 patients (32%), and total arch replacement in 11 (32%). In 5 patients (15%) a direct repair was feasible, and in 7 (21%) a more specific reconstruction was done (see Table 2).

The first patient who died was a 52-year-old male presenting with a 10.5 cm pseudoaneurysm with localized dissection on his distal graft-to-aorta anastomosis 36 months after Bentall repair. He underwent emergent arch replacement, required reoperation for postoperative bleeding, prolonged respiratory therapy including tracheostomy, and transient hemodialysis. This patient died due to multiple organ failure on postoperative day 22.

The second patient suffering hospital death was a 63-year-old male presenting with a 9.2-cm pseudoaneurysm on his proximal graft-to-aorta anastomosis 64 months after thoracoabdominal aortic replacement. He was hospitalized for urgent descending aortic repair (first 8 cm) and demonstrated massive loose atheroma at all aneurysm sites. He died on postoperative day 4 from severe neurologic injury.

The third patient with adverse outcome (a permanent stroke) was a 72-year-old male who had undergone a total arch replacement. He was admitted 72 months after his first operation with a suture-line pseudoaneurysm at his proximal anastomosis site, and underwent elective arch rerepair. Intraoperative findings included a clot in the arch. He suffered a permanent stroke, but was able to be discharged to a rehabilitation facility on postoperative day 61 (see Table 4).

	Comment

Top Abstract Introduction Material and Methods Results Comment References

 
Suture line disruptions are rare but severe complications after thoracic aortic repair, whether or not prosthetic materials are used for reconstruction. Any surgical problem with the anastomosis can give rise to false aneurysm formation or dissection [7, 8]. The interval between the original procedure and the occurrence of the false aneurysm or dissection is highly variable, but suture line disruption mandates reoperation in all patients [9]. The reported incidence of false aneurysm formation/dissection from suture lines varies from 7% to 25% [10].

We believe that the rate of suture line disruption reported here is accurate, because only patient follow-up to the last documented CT scan showing an intact anastomosis was used in calculating disruption rate. The rate of suture line disruption in this series is the lowest incidence hitherto reported. While it is true that the performance of a carefully crafted Teflon felt-supported anastomosis may take slightly longer than use of simpler techniques, the small amount of additional time required is unimportant in determining operative risk with current surgical techniques, particularly hypothermic circulatory arrest and selective cerebral and visceral perfusion. As surgical mortality and morbidity continue to decline, the utility of various operative techniques in preventing long-term complications deserve continuing re-evaluation. It is no longer an acceptable goal simply to have the patient survive an aortic operation: each procedure should assure that the repair will maintain its integrity for decades thereafter.

Hospital mortality for reoperations on the thoracic aorta varies from 6% to 19% [1, 3, 4, 11]. The early mortality rate is of course influenced by many factors: the urgency of operation; the nature of the underlying disease; the technique of reoperation; the type of reintervention, and the indication for the procedure. In our series, in which suture line aneurysms or dissection were the indication for reoperation, the rate of adverse outcome (hospital death or permanent stroke) among the 34 patients was 8% (3 of 34).

With such a small incidence of suture line disruptions, it is not possible to draw any definitive conclusions about where such disruptions are most likely to occur, but their descriptions may nevertheless be of interest. In 28 of 34 patients (82%), suture line disruptions occurred in the ascending aortic wall or the proximal aortic arch; in only 6 of 34 (18%) was the distal aortic arch or descending aortic graft-to-vessel connection involved. Two of 3 patients in our series suffering an adverse outcome at reoperation had very large suture line aneurysms proximal to the innominate artery, where hemodynamic forces are arguably greatest.

In the ascending aorta, suture line disruptions were diagnosed at a mean of 61.5 months after initial operation, whereas distal to the left subclavian artery, aneurysms were detected later, at a mean of 80.7 months postoperatively. The highly variable interval between the original procedure and the occurrence of the suture line disruption [12, 13, 14] reinforces the need for lifelong surveillance: regular annual echocardiography and CT scanning or magnetic resonance imaging enable assessment of the integrity of anastomoses as well as of possible distal progression of the aortic disease for which surgery was originally required.

Overall, our rate of suture line disruptions was very low: 1 per 191 patient-years, or 1 per 296 anastomosis-years. This suggests that using Teflon felt provides a secure, long-lasting graft-to-aorta anastomosis with minimal risk of infection. Careful follow-up can detect the rare instances of suture line failure, and reoperations can be accomplished with a low rate of adverse outcome.

	References

Top Abstract Introduction Material and Methods Results Comment References

 

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