Ann Thorac Surg 2005;79:1422-1424
© 2005 The Society of Thoracic Surgeons
How to do it
The "Eaves" Technique for Distal Anastomosis in Aortic Arch Replacement
Masao Yoshitatsu, MDa,*,
Fumikazu Nomura, MDa,
Koichi Toda, MDa,
Akira Katayama, MDa,
Kentaro Tamura, MDa,
Keijiro Katayama, MDa,
Katsuhiko Ihara, MDa
a Division of Cardiovascular Surgery, National Kure Medical Center, Hiroshima, Japan
Accepted for publication December 10, 2003.
* Address reprint requests to Dr Yoshitatsu, Division of Cardiovascular Surgery, National Kure Medical Center, 3-1, Aoyama, Kure, Hiroshima, 737-0023, Japan;
yoshitatsu{at}kure-nh.go.jp
 |
Abstract
|
|---|
We describe the "eaves" technique, a new method for distal anastomosis in aortic arch replacement. The 1-cm wide eaves were created at the site 3 to 4 cm distal to the graft end. The graft was bound with vessel tape from the eaves to the site proximal to the origin of the first branch to make a working space above the eaves and to facilitate graft handling. Then the native descending aorta was sutured to the eaves easily. The eaves enabled a greater surface contact area between the graft and the inner wall of the aorta and reduced bleeding at the anastomosis.
|
Introduction
|
|---|
Performing total arch replacement through a median sternotomy still has many potential problems, such as bleeding at the distal site of anastomosis associated with inadequate suturing caused by a limited surgical view. Various techniques for the distal anastomosis have been reported [1–7]. We have developed a new simplified technique, the "eaves" technique, and used it successfully in five clinical cases.
|
Technique
|
|---|
Deep hypothermia and selective cerebral perfusion were used for open distal anastomosis. While cooling the body, the graft was prepared. The vascular prostheses used were commercially available aortic arch grafts with 4 limbs (InterVascular, Clearwater, FL). The graft size should be approximately 4 mm smaller than the distal anastomotic site diameter in the descending aorta because the graft wall at the eaves is about 2 mm in thickness. First, we determined the optimal length of graft distal to the fourth branch. Four to five centimeters of the length of the graft was invaginated (Fig 1A). One or two 5-0 polypropylene horizontal mattress sutures were put along the line approximately 1 cm from the "new edge" circumferentially (Fig 1B). Then the invaginated portion of the graft was withdrawn and 1-cm wide eaves, which would become the site of anastomosis, were created (Fig 1C). The eaves were reversed to make anastomosis easier (Fig 1D, E). The graft was bound with vessel tape from the eaves to the site proximal to the origin of the first branch to make a working space above eaves and to bundle four branches and the arch graft together (Fig 2A). This maneuver made the anastomosis easier and more secure by facilitating graft handling and by providing a wide surgical view around the anastomosis (Fig 2B).
View larger version (34K):
[in this window]
[in a new window]
|
Fig 1. (A) Artificial graft was invaginated. (B) A horizontal mattress suture (arrow) was put along the line 1 cm from the "new edge" (arrowhead) circumferentially. (C) The invaginated portion of the graft was then withdrawn and 1-cm wide "eaves" were created. (D, E) The eaves were reversed to make anastomosis easier.
|
|
View larger version (95K):
[in this window]
[in a new window]
|
Fig 2. (A) The graft was bound with vessel tape above the eaves, and both the branches and the graft were bundled together. (B) The working space above the eaves is indicated by the arrow.
|
|
Distal anastomosis was performed as follows: four 4-0 polypropylene U stay sutures were placed between the eaves (upside-underside) and the distal end of the aorta (inside out) evenly. Each suture was passed through polytetrafluoroethylene (PTFE) felt pledgets (1.0 x 0.5 cm) outside the aortic wall (Fig 3A). After the distal end of the graft was inserted into the descending aorta, the four stitches were ligated to fix the underface of the eaves to the inner wall of aorta. Then the aorta was sutured to the eaves with a continuous 4-0 polypropylene suture incorporating a 1.5-cm wide strip of PTFE felt, which was positioned outside the aorta for reinforcement (Fig 3B). After completion of the anastomosis, the binding tape was released. Because no surgical bleeding was found in the anastomoses, additional stitches were not needed for hemostasis.
View larger version (42K):
[in this window]
[in a new window]
|
Fig 3. (A) Four U-stay sutures were placed between the graft and the distal end of the aorta evenly. (B) The aorta was sutured to the eaves with a continuous 4-0 polypropylene suture incorporating a 1.5-cm wide strip of polytetrafluoroethylene felt, which was positioned outside the aorta for reinforcement.
|
|
|
Comment
|
|---|
An everting suture is essential for complete and secure aortic anastomosis; however, it often difficult to evert the graft edge in the distal arch anastomosis because of poor surgical view and a deep anastomotic site [1–7]. Using our technique, it was easy to perform the everting suture as the underface of the eaves was fixed to the inner wall of the aorta by U stitches, and the eaves enabled a greater surface contact area between the graft and the aortic wall.
The invaginated distal anastomosis method has been widely accepted as a method for open distal anastomosis. In this method, the suture line is automatically tightened, and the contact area is increased when the graft is unfolded [1–3]. However, this technique is not available for grafts with four branches because it is difficult to invert the graft including branches. In such cases, the graft must be cut to a straight form without branches and anastomosed to proximal graft with branches after completion of the distal anastomosis. Oda and colleagues [4] described the cuffed anastomosis for distal anastomosis of total arch repair. Compared with this method, our technique has an advantage because the eaves, which were reinforced with horizontal mattress sutures, are structurally more stable than the cuff; and our graft can be used as an elephant trunk when a second operation is necessary for residual thoracic aneurysm. In addition, we obtained a wide view to allow handling of the graft by binding the proximal side and branches with tape.
In conclusion, the eaves technique of distal anastomosis represents a useful additional tool for the surgeon.
|
References
|
|---|
- Griepp RB, Stinson EB, Hollingsworth JF, Buehler D. Prosthetic replacement of the aortic arch. J Thorac Cardiovasc Surg. 1975;70:1051–1063[Abstract]
- Svensson LG. 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]
- Emery RW, Arom KV, Nicoloff DM. Modification of the elephant trunk procedure for treatment of acute aortic dissection. J Card Surg. 1995;101:65–67
- Oda K, Akimoto H, Hata M, et al. Use of cuffed anastomosis in total aortic arch replacement. Ann Thorac Surg. 2003;76:952–953[Abstract/Free Full Text]
- Carrel T, Berdat P, Kipfer B, Eckstein F, Schmidli J. The reversed and bidirectional elephant trunk technique in the treatment of complex aortic aneurysms. J Thorac Cardiovasc Surg. 2001;122:587–591[Abstract/Free Full Text]
- Sakamoto T, Yoshida T, Sugano T, Kudoh A, Susuki A. Simplified technique for hemi-arch replacement during open distal anastomosis: the "calla" method. Ann Thorac Surg. 1996;61:1021–1023[Abstract/Free Full Text]
- Ravichandran PS, Floten HS, Swanson JS, et al. Reversed bevel technique for anastomosis at the aortic arch. Ann Thorac Surg. 1996;61:245–246[Abstract/Free Full Text]
This article has been cited by other articles:
|
|
|
|
 
D. G. Nezic, A. M. Knezevic, M. V. Cirkovic, and I. C. Stojanovic
Inverted Graft for Construction of an Open Distal Anastomosis in Ascending Aorta and/or Arch Replacement: An Old Technique
Ann. Thorac. Surg.,
August 1, 2007;
84(2):
712 - 713.
[Full Text]
[PDF]
|
|
|
|
|
|
|
N. Tamura, T. Komiya, G. Sakaguchi, and T. Kobayashi
'Turn-up' anastomotic technique for acute aortic dissection
Eur. J. Cardiothorac. Surg.,
March 1, 2007;
31(3):
548 - 549.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
