Ann Thorac Surg 2006;81:1552
© 2006 The Society of Thoracic Surgeons
Correspondence
Aortic Arch Replacement Using a Trifurcated Graft
Teruhisa Kazui, MD, PhD,
Abul Hasan Muhammad Bashar, MBBS, PhD
First Department of Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Hamamatsu City, 431-3192 Japan
(Email: tkazui{at}hama-med.ac.jp).
To the Editor:
We read with great interest the article by Spielvogel and colleagues [1] on the use of a trifurcated graft to replace the aortic arch. We were truly impressed by their surgical results in a series of 109 nonemergent patients who underwent aortic arch replacement for various aortic arch pathologies with the use of a trifurcated graft. The cerebral protective adjuncts used were deep hypothermic circulatory arrest (DHCA) and antegrade selective cerebral perfusion (SCP). Although the points regarding the advantages of the trifurcated graft in the surgical strategy adopted by the authors are well taken, we have several concerns about some aspects of this strategy:
- 1 The purpose of operating on an aneurysmal aortic arch is to excise and exclude the aneurysmal segment of the aorta as far as possible to eliminate or reduce the risk of rupture. The elephant trunk not only facilitates the second-stage operation, but it is also expected to reduce the risk of rupture of the remaining aneurysm when used in an appropriate fashion. The authors in the current series apparently performed the distal aortic anastomosis at or near the proximal aneurysm neck without actually resecting much of the aneurysm. As illustrated in Figure 2 of the article, this results in an elephant trunk that never reaches the normal aortic lumen distally, and instead floats within the nonresected aneurysm sac. This leaves the possibility of turbulent blood flow from the elephant trunk hitting the aneurysmal aortic wall to increase the chance of rupture. We believe that the basic objective of preventing aneurysm rupture is not adequately fulfilled with such a surgical strategy. The authors do not discuss the second-stage operation in these patients. It would be interesting to know how many of these patients required the second operation in the early postoperative period due to continued aneurysm enlargement.
- 2 There were 35 patients in this series with chronic aortic dissection. Did the authors resect the dissected intimal membrane while inserting the elephant trunk to ensure flow into both the true and false lumen?
- 3 Because the authors do not open the aneurysm before neck-vessel anastomoses, we believe it should be technically difficult to get consistent access to the left subclavian artery (ie, it is often deep and fairly posterior in location).
- 4 The cerebral arteries that are anastomosed separately to the branches of the graft are fed by a common trunk that is anastomosed to the main graft proximally. This makes the whole cerebral circulation dependent on the patency of the common trunk. Given the fact that this common trunk is a pretty long conduit, one can not help worrying about the possibility of kinking or thrombosis of this graft and its dreadful consequences.
- 5 The authors perform the neck vessel anastomoses under DHCA. We think that it would be safer to start the antegrade SCP through the right axillary artery immediately after the commencement of DHCA. This would not only shorten the duration of DHCA, but would also allow the temperature to be raised to somewhere around 25° C.
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References
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- Spielvogel D, Halstead JC, Meier M, et al. Aortic arch replacement using a trifurcated graftsimple, versatile, and safe. Ann Thorac Surg 2005;80:90-95.[Abstract/Free Full Text]
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