Ann Thorac Surg 2007;83:1906-1907
© 2007 The Society of Thoracic Surgeons
How To Do It
A "Double Overlap" Suture Technique for the Proximal Attachment of a Composite Graft to the Aortic Annulus
John A. Rousou, MD*,
Abdallah K. Alameddine, MD,
Chunjie Yang, MD
Division of Cardiac Surgery, Baystate Medical Center, Springfield, Massachusetts
Accepted for publication May 24, 2006.
* Address correspondence to Dr Rousou, Baystate Medical Center, 759 Chestnut St, Suite 4628, Springfield, MA 01107 (Email: susan.parent{at}bhs.org).
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Abstract
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Repair of an aortic root aneurysm using a composite graft is sometimes complicated by proximal suture line bleeding, which may be very difficult to control. We adopted a previously described technique of "double overlap" sutures on the annulus and the prosthetic cuff, which has virtually eliminated this complication.
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Introduction
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Bleeding from the proximal suture line of a composite aortic graft sutured to the aortic annulus can be very difficult to repair and control, especially after the attachment of the coronary artery buttons to the graft [1]. A "double overlap" technique previously described in a correspondence communication [2] was used in all patients undergoing aortic root replacement with composite grafts by the primary author for repair of aortic root aneurysms in the past 10 years. The technique virtually eliminated all bleeding arising from the graft to annulus suture line.
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Technique
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After the institution of cardiopulmonary bypass and cardioplegic arrest, the aortic root aneurysm is excised leaving only the two coronary buttons and 5 to 10 mm of aortic wall attached to the aortic annulus. The abnormal aortic valve is also excised and the appropriate size composite graft is selected.
Interrupted pledgeted sutures are then started on the annulus in an everting mattress fashion, with the pledgets lying on the outside of the annulus. The first needle pass of each subsequent mattress suture is placed behind the second thread of the previous suture, overlapping by 1 to 2 mm. This is easily assured by observing the needle entry both on the outside and especially on the inside of the aortic annulus (see Fig 1A). Care must be exercised to avoid the needle from piercing the previous suture. If doubt exists, this can be tested by a gentle pull on the previous suture while the needle is in the annulus or following its passage. All interrupted mattress sutures are inserted in this fashion. The sutures are laid out in sequence with two colors alternating in Suture Guides (Deknatel, Teleflex Medical, Research Triangle Park, NC), which clearly identify and separate the first from the second limb of each mattress suture, as well as the mattress sutures themselves from each other.
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Fig 1. Part A illustrates the overlapping mattress sutures on the aortic annulus, whereas part B illustrates the same overlapping pattern on the prosthetic sewing cuff. The first three mattresses are depicted as a thin line (first), a broken line (second) and a bold line for clarity.
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The composite graft is then brought to the operative field, and the annular sutures are passed through the sewing cuff of the prosthetic valve. The same overlap technique is again used on the graft, placing the first needle of the subsequent mattress suture behind the second thread of the previous suture in the prosthetic cuff, overlapping by approximately 1 to 2 mm again. Care must be exercised again to avoid piercing the previous suture while overlapping (see Fig 1B). A slight overlap of the pledgets may be seen on the annulus and the cuff of the prosthesis, which is of no consequence. The width of the mattress bites on the annulus and the cuff for each mattress suture must be slightly wider than normal by approximately 1 or 2 mm to accommodate the overlaps. When all sutures are passed through the cuff, the graft is lowered into the annulus and all sutures are tied and divided. The passing of mattress sutures through the prosthetic cuff and their subsequent tying is aided by the alternating colors, their prior separation on the suture guides, and the placement of hemostats on individual mattress sutures as they are sequentially passed through the cuff prior to tying them. By following this technique, confusion is avoided and the operation can proceed expeditiously. The proximal suture line can then be tested for bleeding by filling the left ventricular cavity with blood using the vent catheter and manually squeezing the left ventricle gently into the clamped aortic graft. After a watertight suture line is assured, the left and right coronary buttons are attached to the graft in that order. Coronary button suture lines are tested for bleeding by administering blood cardioplegia antegrade through the aortic graft, followed by the performance of the distal suture line of the graft onto the divided aorta using running monofilament suture. The operation is then completed in a conventional manner.
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Comment
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Repair of aortic root aneurysms especially in the setting of acute aortic dissection can be fraught with coagulopathy and/or fragile tissues. These can result in intraoperative and postoperative bleeding from suture lines into the mediastinum that could be difficult to control, especially in aortic root replacement with coronary button reimplantation onto a composite graft. Any technique such as the one described by Bayfield and Kron [1] that can minimize or eliminate this problem leads to less morbidity, mortality, and improved patient care. Since adopting the overlap technique described by Baciewicz [2] 10 years ago (we have used it in 30 cases so far), bleeding from the proximal suture line of a composite graft to the annulus has been virtually eliminated. The technique is easy and reproducible and only adds a few minutes to a conventional aortic valve replacement technique using mattress sutures. We feel the benefits of this technique are well worth the time and effort invested.
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References
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- Bayfield MS, Kron IL. Reducing bleeding after replacement of the aortic root Ann Thorac Surg 1995;60:1130-1131.[Abstract/Free Full Text]
- Baciewicz Jr. FA. Reducing aortic root bleeding Ann Thorac Surg 1996;61:1587.[Medline]
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Abstract
Introduction
