Ann Thorac Surg 2007;83:326-328
© 2007 The Society of Thoracic Surgeons
How To Do It
Tube-Graft Inversion for the Construction of an "Open" Distal Anastomosis During Ascending Aortic Replacement: A New Technique
Christos Alexiou, FRCS, PhD,
Andrzej W. Sosnowski, MD, FRCS*
Department of Cardiac Surgery, Glenfield Hospital, University Hospitals of Leicester, Leicester, United Kingdom
Accepted for publication March 10, 2006.
* Address correspondence to Dr Sosnowski, Glenfield Hospital, Groby Rd, Leicester, LE3 9QP United Kingdom (Email: andrzej.sosnowski{at}uhl-tr.nhs.uk).
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Abstract
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For the construction of a distal "open" anastomosis during ascending aortic replacement, a tube-graft is placed opposite to the transected aorta. We describe an alternative technique. The tube-graft is inverted and positioned within the aortic arch in a way that brings the entire circumference of the distal end of the tube-graft next to the circumference of the transected aorta. An end-to-end anastomosis is then fashioned with a running suture, the needle of which goes through the aorta and the tube-graft in a single pass. This technique permits easy, accurate, and fast suture placement, producing a hemostatic distal anastomosis within a short circulatory arrest time.
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Introduction
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During ascending aortic replacement with a tube-graft, hypothermic circulatory arrest (HCA) may be required [1, 2]. In this setting, the distal end of a tube-graft is placed opposite to the end of the transected aorta and an end-to-end anastomosis is performed [3, 4]. In this article we describe an alternative technique for the fashioning of the distal "open" end-to-end anastomosis between the transected ascending aorta and the tube-graft.
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Technique
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This technique is used in patients having aortic aneurysms involving the distal ascending aorta (with or without concomitant aortic valve or root pathology) and type A aortic dissections.
Chronic Aneurysm
After a median sternotomy, cardiopulmonary bypass is established with a two-staged right atrial and an aortic cannula, and systemic cooling to a nasopharyngeal temperature of 17°C is commenced. The heart is decompressed with a vent inserted in the left ventricle through the right superior pulmonary vein. If required, aortic valve replacement and distal coronary artery anastomoses are carried out after aortic clamping, administration of cold blood cardioplegia, and transection of the ascending aorta above the sinotubular junction. If aortic root replacement procedure is needed, it is initiated at this stage and continued until the desired temperature (17°C) is reached. At this point, the patient is placed in the head-down position, the circulation is interrupted, and blood is drained into the venous reservoir of the cardiopulmonary bypass circuit. The ascending aorta is transected distally, close to the origin of the aortic arch. The ascending aortic specimen is removed and sent for histologic examination. A Dacron (Vascutek, Inchinnan, Renfrewshire, Scotland, UK) tube-graft of appropriate size with a side arm is selected, its distal end being cut obliquely and held opposite to the transected aorta. Then the tube-graft is inverted by pulling its distal end downward and outward and pushing its proximal end upward and inward (Figs 1a–1d,
2a–2c). The inverted tube-graft is placed within the aortic arch in a way that brings the entire circumference of the inverted distal end of the graft side-by-side to the entire circumference of the transected ascending aorta (Figs 1e–1g, 3a). An end-to-end anastomosis between the transected aorta and the tube-graft is performed with a continuous over and over 3-0 Prolene suture (Ethicon, Somerville, NJ), the needle of which goes through the aorta (out 
in) and the tube-graft (in out) in a single pass (Fig 1g). If chosen, a strip of Teflon (Bard Inc, Impra Inc, Tempe, AZ) can be incorporated in the suture line (Fig 3a). On completion of the anastomosis (Fig 3a), the side arm of the graft and the entire tube-graft are pulled out from the aortic arch (Figs 1h, 1i, 3b, 3c), and retrograde systemic perfusion through the right atrial cannula is commenced. Once the air from the tube-graft is fully removed, antegrade systemic perfusion is re-established through its sidearm and a clamp is proximally applied to it (Fig 3c). Systemic re-warming is started, and the proximal anastomosis and other parts of the operation are carried out in the standard fashion.
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Fig 1. The Dacron (Vascutek, Inchinnan, Renfrewshire, Scotland, UK) tube-graft is inverted by pulling its distal end downward and outward and pushing its proximal end upward and inward (a–d) and is positioned within the aortic arch in a way that brings the entire circumference to its distal end (marked with black color throughout) next to that of the transected ascending aorta (e, f). An end-to-end anastomosis between the transected aorta and the tube-graft is performed, during which the needle of the suture passes through the aorta and the tube-graft in a single pass (g). Upon completion of the anastomosis, the tube-graft is pulled out from the aortic arch (h, i).
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Fig 2. The Dacron (Vascutek, Inchinnan, Renfrewshire, Scotland, UK) tube-graft is inverted by pulling its distal end downward and outward and pushing its proximal end upward and inward (a, b, c). The black arrows point toward the distal end of the tube-graft.
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Fig 3. Photographs taken from a patient undergoing aortic root replacement for chronic type A dissection. On completion of the end-to-end anastomosis between the inverted distal end of the tube-graft and the transected ascending aorta (a), the sidearm of the tube-graft (b) and the entire tube-graft (c) are pulled out from the aortic arch. A clamp is applied across the graft and antegrade perfusion is commenced through its sidearm.
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Aortic Dissection
In cases of aortic dissection, cardiopulmonary bypass is instituted with a two-staged right atrial cannula and a cannula that is introduced in the ascending aorta through the apex of the left ventricle and the aortic valve under transoesophageal guidance [5]. This ensures that the cannula lies within the true aortic lumen, which helps to avoid malperfusion. A left ventricular vent through the right superior pulmonary vein is also inserted. The ascending aorta is not clamped. The patient is cooled down to a nasopharyngeal temperature of 17°C, the circulation is interrupted, and the operation proceeds (with respect to the "open" distal anastomosis) as previously described.
Brief Summary of Clinical Experience
This technique has been used during a 1-year period (ie, from September 2004 to September 2005) in 14 patients (ie, 8 men and 6 women; mean age, 68 ± 10 years; range, 45 to 83 years). A senior consultant cardiac surgeon (AWS) performed 8 of these cases (ie, 4 chronic aneurysms, 3 acute type A dissections, and 1 chronic type A dissection) and supervised his senior specialist registrar (CA) in performing 6 of the cases (all chronic aneurysms). The mean circulatory arrest time in consultant and specialist registrar cases was 8.5 minutes (range, 7 to 12 minutes) and 20 minutes (range, 18 to 27 minutes), respectively. The anastomoses were hemostatic and required only occasional additional sutures; no patient was reopened for bleeding. All these patients remain well with satisfactory appearances of the distal aorto-tubular anastomoses on their routine postoperative computed tomographic scans.
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Comment
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The standard technique for the fashioning of the distal anastomosis during an ascending aortic replacement can be used either after aortic clamping and cardioplegic arrest or with an "open" aorta in the setting of HCA [1–4]. The alternative approach described in this article involves placing the inverted tube-graft within the aortic arch, and thus it can be used only for the construction of an "open" distal anastomosis.
We believe that in this setting the use of the inverted tube-graft technique may be advantageous. Bringing the entire circumference of the distal end of the inverted tube-graft virtually next to the entire circumference of the transected aorta (Fig 1f, 1g, 1h) facilitates accurate suture placement and a very precise match between the two anastomotic ends. This may reduce technical imperfections and the resultant bleed from the anastomotic suture line. In our experience, placement of additional sutures to control the anastomotic leak has been exceptional, and no patient was reopened for bleeding. Moreover, because the needle of the suture passes through the graft and the aorta at once (as opposed to the two passes required with the standard technique), the HCA time is considerably shortened. Indeed, with the use of this technique, the senior author (AWS) observed approximately a 50% reduction in his HCA time compared with the standard approach. With respect to the indications and applicability, the graft inversion technique can be used in elective or emergency procedures involving aortic aneurysm or dissection, or both. Last but not least, the technique is readily reproducible and can be safely taught to the cardiothoracic trainees, who in their initial hands-on exposure to this type of surgery can perform the distal "open" anastomosis within an acceptable HCA time. For these reasons we now routinely use the tube-graft inversion technique, and we would like to recommend it as a useful alternative approach for ascending aortic replacement under HCA.
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References
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- Bonser RS. Circulatory arrestIn: TJ Gardner, TL Spray, editors. Operative cardiac surgery. 5th ed.. London: Arnold; 2004. pp. 63-71.
- Pretre R, Turina MI. Deep hypothermic circulatory arrestIn: Cohn LH, Edmunds Jr LH, editors. Cardiac surgery in the adult. 2nd ed.. New York, NY: McGraw-Hill; 2003. pp. 401-412.
- Lytle BW. Ascending aortic aneurysmIn: TJ Gardner, TL Spray, editors. Operative cardiac surgery. 5th ed.. London: Arnold; 2004. pp. 435-447.
- Anderson CA, Rizzo RJ, Cohn LH. Ascending aortic aneurysmsIn: Cohn LH, Edmunds LHJr, editors. Cardiac surgery in the adult. 2nd ed.. New York, NY: McGraw-Hill; 2003. pp. 1123-1148.
- Robiscek F. Apical aortic cannulation: application of an old method with new paraphernalia Ann Thorac Surg 1991;51:330-332.[Abstract/Free Full Text]
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Abstract
Introduction
