HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Antonio D’Andrilli Mohsen Ibrahim Federico Venuta Tiziano De Giacomo Erino A. Rendina Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by D’Andrilli, A. Articles by Rendina, E. A. Search for Related Content PubMed PubMed Citation Articles by D’Andrilli, A. Articles by Rendina, E. A. Related Collections Lung - cancer

Ann Thorac Surg 2005;80:357-358
© 2005 The Society of Thoracic Surgeons

---

How to do it

Glutaraldehyde Preserved Autologous Pericardium for Patch Reconstruction of the Pulmonary Artery and Superior Vena Cava

^a Division of Thoracic Surgery, Sant’Andrea Hospital
^b Policlinico Umberto I, University of Rome "La Sapienza," Rome, Italy

Accepted for publication February 3, 2004.

^_* Address reprint requests to Dr Rendina, Division of Thoracic Surgery, Ospedale Sant’Andrea, via di Grottarossa 1035, 00189 Rome, 00161 Italy; (Email: erinoangelo.rendina{at}tin.it).

	Abstract

Top Abstract Introduction Technique Comment References

 
We describe a new employment of glutaraldehyde preserved autologous pericardium for patch reconstruction of the pulmonary artery (PA) and superior vena cava (SVC). This technique was devised to minimize technical problems related to the use of fresh pericardium such as excessive elasticity and tendency to curl. We have successfully employed this procedure in three cases of reconstruction of the PA and in two cases of reconstruction of the SVC.

	Introduction

Top Abstract Introduction Technique Comment References

 
Resection and patch or prosthetic reconstruction of the pulmonary artery (PA) and superior vena cava (SVC) are current practice in thoracic surgery. In the past two decades a variety of techniques and materials have been proposed for repairing these low-pressure vessels after oncological resection [1–5]. Biological materials, such as autologous or bovine pericardium, azygos vein, and saphenous vein have achieved greater acceptance if compared with synthetic materials because of improved biocompatibility, a lower risk of infection and thrombosis, and lower costs.

We have extensively employed autologous pericardium for vascular reconstruction in thoracic surgery [1–5]. Fresh pericardium is however difficult to handle, trim to the appropriate size, and suture to the vascular wall. We have therefore devised a method of intraoperative fixation by glutaraldehyde that makes the autologous pericardial leaflet stiffer and harder and ultimately easier to use. We hereby describe our technique.

	Technique

Top Abstract Introduction Technique Comment References

 
Technical details regarding the mobilization of the PA and SVC infiltrated by the tumor, to achieve full control of the vessel for clamping procedures and surgical resection, have been extensively reported elsewhere [2, 5] (Fig 1). Intravenous injection of 3000–5000 U of heparin sodium is administered before clamping the vessel.

View larger version (157K): [in this window] [in a new window]   Fig 1. Left upper lobectomy with pulmonary artery (PA) reconstruction using a pericardial patch. Operative field after preparation of the main left PA. The pericardium is opened widely and the PA window and left atrium can be observed.

Among the biological materials currently employed for patch reconstruction our preference refers to the autologous pericardium. The necessity to confer to the fresh autologous pericardial leaflet for adequate stiffness and improved handiness has induced us to devise a method of fixation that can be used intraoperatively and is comparable with those in current use for the preparation of biological heart valves [6].

Once a 0.6% glutaraldehyde-buffered solution has been prepared, the autologous pericardium is harvested anteriorly to the phrenic nerve and the pericardial defect is left open. The pericardial leaflet is dipped in the solution for 10 minutes. The patch is then washed in NaCl 0.9% solution and trimmed to the appropriate size. It is befitting to harvest an amount of tissue larger than the vascular defect because of the shrinkage induced by gluteraldehyde and to tailor the pericardium on the resected part rather than on the vascular defect. The visceral aspect of the pericardium is luminen oriented.

The patch is then secured to the vascular wall by two stay sutures. The inferior stay suture is not tied and is used only to keep the patch in place. It is removed when the suture line reaches its level. Suturing the patch will be considerably simplified at this point because the edges of the fixed pericardium seem stiffer and the leaflet illustrates minimal elastic recoil. It is therefore easier to place the suture bites at the appropriate distance.

The suture is performed using running 5-0 or 6-0 monofilament nonabsorbable material. The suture line has to be carefully checked at the end of the reconstructive procedure, because the PA and SVC are low-pressure vessels and leakage from the suture line may pass unnoticed intraoperatively. Mild anticoagulant therapy (8000 U per day of low weight heparin subcutaneously) is administered for the first postoperative week.

We have performed this technique in 3 patients who required reconstruction of the PA and in 2 patients who required reconstruction of the SVC for lung cancer infiltration. PA reconstruction was associated to a left upper sleeve lobectomy in 1 patient and to a standard left upper lobectomy in the other 2 patients. In all 3 patients the primary tumor infiltrated the concave surface of the interlobar pulmonary artery and the origin of the upper lobe branches. SVC reconstruction was associated to a right upper sleeve lobectomy in 1 patient and to a standard right upper lobectomy in the other patient. All 5 patients were male with an age range of 50–68 years (mean: 62 years). All of the operations were performed through a lateral muscle sparing thoracotomy on the fifth intercostal space. Mean clamping time was 21 minutes (range: 18–25) for the PA reconstructive procedures and 23 minutes (range: 20–26) for SVC reconstruction. Postoperative in-hospital stay ranged from 5–7 days (mean: 5.8 days). We observed no intraoperative or postoperative complications related to the reconstructive procedures. The only postoperative complication was a persistent air leak in 1 patient undergoing PA reconstruction associated with left upper lobectomy. The patient was discharged with a Heimlich valve that was removed 1 week later. All the patients are well and without evidence of disease 6 and 12 months postoperatively.

	Comment

Top Abstract Introduction Technique Comment References

 
We have previously reported [1, 5] our experience regarding the extensive use of pericardial patch or conduit for great vessel reconstruction. In particular we have preferred autologous pericardium because it has a number of advantages: it illustrates adequate thickness and resistance, it is cost-free and available on both sides of the chest, it has superior biocompatibility if compared with bovine pericardium and the amount of tissue is also sufficient for large defect repair, and moreover its harvesting does not require a separate procedure and offers a larger amount of tissue if compared with venous patches. However fresh pericardium indicates some technical limits because it markedly shrinks and curls making the adaptation of the patch to the vascular wall defect more difficult to achieve. Also suturing the patch to the vessel is difficult in that uneven bites and bleeding sites may result. Conversely bovine pericardium displays little elasticity and exhibits even and stiff edges that considerably reduce the pitfalls of harvesting, trimming, and suturing autologous pericardium. The use of the fixation technique described here improves the technical features of fresh pericardial tissue. The glutaraldehyde preserved pericardium indicates no tendency toward shrinkage or curling, making the tailoring of the patch and its suturing to the vascular wall easier. This method of preservation by gluteraldehyde is inexpensive, is easy to perform, and does not prolong surgical duration. We also believe that it could be effective with regard to minimizing the risk of bleeding from the patch suture related to the elastic recoil of the autologous pericardium in the early postoperative period. In our past experience [2] this complication occurred occasionally with blood losses up to 1000 ml in the second to fourth postoperative day when changes in tension applied on the vessel may distort the suture line and open bleeding sites.

	References

Top Abstract Introduction Technique Comment References

 

1. Rendina EA, Venuta F, De Giacomo T, et al. Sleeve resection and prosthetic reconstruction of the pulmonary artery for lung cancer Ann Thorac Surg 1999;68:995-1002.[Abstract/Free Full Text]
2. Rendina EA, Venuta F. Reconstruction of the pulmonary arteryIn: Pearson FG, et al. editor. Thoracic Surgery. 2nd ed. Philadelphia: Churchill Livingstone; 2002. pp. 1013-1027.
3. Piccione Jr W, Faber LP, Warren WH. Superior vena caval reconstruction using autologous pericardium Ann Thorac Surg 1990;50:417-419.[Abstract]
4. Shrager JB, Lambright ES, McGrath CM, et al. Lobectomy with tangential pulmonary artery resection without regard to pulmonary function Ann Thorac Surg 2000;70:234-239.[Abstract/Free Full Text]
5. Rendina EA, Venuta F, De Giacomo T, et al. Induction chemotherapy for T4 centrally located non-small cell lung cancer J Thorac Cardiovasc Surg 1999;117:225-233.[Abstract/Free Full Text]
6. Love CS, Love JW. The autologous tissue heart valvecurrent status. J Cardiac Surg 1991;6:499-507.[Medline]

This article has been cited by other articles:

				D. Galetta and L. Spaggiari Reply to the editor. J. Thorac. Cardiovasc. Surg., December 1, 2007; 134(6): 1601 - 1602. [Full Text] [PDF]

				F. Rea, G. Marulli, and F. Sartori Superior vena cava replacement for lung cancer using a heterologous (bovine) prosthesis: Preliminary results J. Thorac. Cardiovasc. Surg., February 1, 2007; 133(2): 592 - 592. [Full Text] [PDF]

				L. Spaggiari, F. Leo, G. Veronesi, P. Solli, D. Galetta, B. Tatani, F. Petrella, and D. Radice Superior Vena Cava Resection for Lung and Mediastinal Malignancies: A Single-Center Experience With 70 Cases Ann. Thorac. Surg., January 1, 2007; 83(1): 223 - 230. [Abstract] [Full Text] [PDF]

				A. D'Andrilli, A. M. Ciccone, M. Ibrahim, F. Venuta, and E. A. Rendina A new technique for prosthetic reconstruction of the superior vena cava J. Thorac. Cardiovasc. Surg., July 1, 2006; 132(1): 192 - 194. [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Antonio D’Andrilli Mohsen Ibrahim Federico Venuta Tiziano De Giacomo Erino A. Rendina Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by D’Andrilli, A. Articles by Rendina, E. A. Search for Related Content PubMed PubMed Citation Articles by D’Andrilli, A. Articles by Rendina, E. A. Related Collections Lung - cancer