Ann Thorac Surg 2007;84:677-679
© 2007 The Society of Thoracic Surgeons
How To Do It
Simple and Uniform Technique for Combined Repair of Aortic Arch and Root Replacement
Kazuhiro Taniguchi, MD, PhD*,
Satoru Kuki, MD, PhD,
Toshiki Takahashi, MD, PhD,
Takafumi Masai, MD, PhD,
Koichi Toda, MD, PhD,
Hajime Matsue, MD,
Hiroki Hata, MD
Department of Cardiovascular Surgery, Japan Labour Health and Welfare Organization, Osaka Rosai Hospital, Sakai, Japan
Accepted for publication December 27, 2006.
* Address correspondence to Dr Taniguchi, Department of Cardiovascular Surgery, Japan Labour Health and Welfare Organization, Osaka Rosai Hospital, Sakai, 591-8025, Japan (Email: kazuhiro{at}orh.go.jp).
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Abstract
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We present herein a simple and uniform repair technique for combined aortic arch and root aneurysms. Our method is performed under an open distal procedure and includes selective antegrade cerebral perfusion, adequate myocardial preservation, a four-branched composite valve graft, and a long elephant trunk anastomosis proximal to the innominate artery. The technique was designed to reduce morbidity and mortality associated with aortic arch and root replacements, as well as allow for easier performance of subsequent downstream operations.
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Introduction
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A composite valve graft insertion is usually performed in patients who have enlargement of the aortic annulus and sinotubular ridge or the sinuses of Valsalva [1–3]. If the aneurysm involves the aortic arch or is more distal in the aorta, replacement of the aortic arch is also required. Those situations are frequently encountered, especially in patients with cystic medial necrosis, mega aorta, or Marfan syndrome. For aortic arch repair, Kazui and coworkers [4] reported a method of total arch replacement using a four-branched arch graft with the aid of antegrade selective cerebral perfusion, and their technique has become widely used. In patients with more extensive aortic aneurysms, a multiple-stage approach using an elephant trunk has also been widely implemented [5]. However, treatment for the combined pathologies associated with the aortic arch and aortic root remains a challenge because of the cumulative risks faced when performing two major surgical procedures.
In 1998, we developed a modified technique for total aortic arch replacement and have reported satisfactory early and midterm results [6]. Thereafter, our experience with a four-branched graft and long elephant trunk for aortic arch reconstruction allowed us to develop a less invasive and easy-to-perform repair technique for concomitant replacement of the aortic root, ascending aorta, and aortic arch.
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Technique
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After the induction of anesthesia, a catching catheter (Amplatz Goose Neck Snares; ev3 Inc, Plymouth, MN) is introduced into the aortic arch through the left femoral artery. The ascending aorta and arch vessels are dissected through a median sternotomy, the right and left axillary arteries are exposed, and an 8-mm tube graft is anastomosed end to side to the axillary artery. The left graft is then introduced into the pericardial space through a retroclavicular tunnel.
Cardiopulmonary bypass is established through the bicaval and right axillary artery cannulas, and cooling down to 25°C is begun. After excision of the aortic valve, an appropriately sized four-branched arch graft (Hemashield Platinum, Woven Double Velour; Boston Scientific Corporation, Wayne, NJ) is selected. With the valve annular sutures in place, the four-branched composite valve graft is prepared by suturing an appropriately sized prosthetic valve at the proximal end of the arch graft at a location 15 to 20 mm under the lowest branch. The aortic root is then replaced with the four-branched composite valve graft using a modified Bentall method. Of importance, the composite valve graft is sutured in the direction toward the aortic annulus so that the three branches of the graft are directed toward and exiting from the right lateral aspect of the ascending aorta, which corresponds to the commissure between the right coronary and noncoronary cusps (Fig 1).
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Fig 1. (A) A cardiopulmonary bypass is established with bicaval venous drainage and a right axillary arterial return (arrow). (B) The four-branched composite valve graft is sutured in the direction of the aortic annulus, so that the line formed by the three branches corresponds to the commissure between the right coronary and noncoronary cusps.
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Once the aortic root procedure is completed and the target temperature reached, an angled 3-mm 9F cannula (3.0 mm, Stoeckert Pediatric Aortic Cannula; Sorin Group Deutschland, GMBH, Munchen, Germany), is inserted into the left common carotid artery along with a left axillary artery graft, selective cerebral perfusion is started using an additional roller pump and a three-way connector to perfuse those arch vessels with a flow rate of 10 mL · kg–1 · min–1, and systemic perfusion is discontinued. Next, the aortic clamp is removed, and the ascending aorta is transected just proximal to the innominate artery. A divided tube graft ("elephant trunk," 15 to 20 cm) is inserted into place in the descending aorta by pulling the edge of the elephant trunk with the aid of a catching catheter under an open distal condition (Fig 2). A distal anastomosis is then performed at the base of the innominate artery between the composite valve graft and the distal aorta, incorporating the elephant trunk graft using a simple running suture. After the distal anastomosis, systemic perfusion is restarted through the fourth side branch of the graft while selective cerebral perfusion is maintained, and the patient is rewarmed. Finally, the arch vessels are reconstructed by an end-to-end anastomosis to the individual branch graft during the rewarming period, and selective cerebral perfusion flow is reduced as the branch is reconstructed. The left subclavian artery is simply ligated or closed with clipping or sutures (Fig 3).
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Fig 2. A divided tube graft ("elephant trunk") is inserted into the descending aorta by pulling the edge of the elephant trunk (inset) with the aid of a catching catheter under an open distal condition during selective cerebral perfusion (arrows).
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Fig 3. (A) A distal anastomosis is performed at the base of the innominate artery. (B) The arch vessels are reconstructed individually while rewarming the patient. The distal end of the elephant trunk in this case was marked with metal clips.
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Since 2001, we have performed this technique in 7 patients, with a mean age of 55 years (range, 25 to 73), and have seen excellent results. The mean open distal (systemic circulatory arrest) and selective cerebral perfusion times were 24 ± 4 and 86 ± 12 minutes, respectively, and the mean total cardiopulmonary bypass time was 276 ± 41 minutes. There were no hemorrhagic or neurologic complications, and none of the patients showed graft kinking or peripheral thromboembolism. The mean duration of follow-up was 27 months (range, 21 to 62). One patient with Marfan syndrome successfully underwent a second-stage repair of descending and thoracoabdominal aneurysms 34 months after the initial operation, and another patient with Marfan syndrome is awaiting a future thoracoabdominal aortic repair. As for the remaining 5 patients, postoperative computed tomography scans showed a complete obliteration of the distal aneurysmal lumen by thrombus formation around the elephant trunk after implementation of our thromboexclusion technique.
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Comment
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The technique described herein is easy and simple to perform, and does not increase morbidity or mortality associated with concomitant replacements of the aortic arch and aortic root. An advantage of our method is that all the anastomoses are visible to the surgeon; thus, any bleeding points can be controlled easily before the cardiopulmonary bypass is discontinued. Further, the period required for insertion of a long elephant trunk and distal anastomosis (open distal time) is considerably shorter than that for the standard method of elephant trunk procedure with a distal anastomosis beyond the left subclavian artery [5], or between the left carotid and subclavian arteries [7].
Although uncertainty remains regarding the optimal length of the elephant trunk and the necessity of a stented end on the trunk [8], we believe that our technique is reproducible and uniformly applicable to patients with extensive aortic aneurysms from the aortic annulus to below the mid descending aorta.
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Acknowledgments
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This research was supported by research funds to promote the hospital functions of Japan Labour Health and Welfare Organization.
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References
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- Bentall HH, De Bono A. A technique for complete replacement of the ascending aorta Thorax 1968;23:338-339.[Abstract/Free Full Text]
- Kouchoukos NT, Marshall Jr WG, Wedige STA. Eleven-year experience with composite graft replacement of the ascending aorta and aortic valve J Thorac Cardiovasc Surg 1986;92:691-705.[Abstract]
- Svensson LG. Approach to the insertion of composite valve graft Ann Thorac Surg 1992;54:376-378.[Abstract]
- Kazui T, Washiyama N, Bashar AHM, et al. Total arch replacement using aortic arch branched graft with the aid of antegrade selective cerebral perfusion Ann Thorac Surg 2000;70:3-8.[Abstract/Free Full Text]
- Borst HG, Frank G, Schaps D. Treatment of extensive aortic aneurysms by a new multiple-stage approach J Thorac Cardiovasc Surg 1988;95:11-13.[Abstract]
- Kuki S, Taniguchi K, Masai T, et al. An alternative approach using long elephant trunk for extensive aortic aneurysm: elephant trunk anastomosis at the base of the innominate artery Circulation 2002;106(Suppl 1):I253-I258.[Medline]
- Svensson LG, Kaushik SD, Marinko E. Elephant trunk anastomosis between left carotid and Subclavian arteries for aneurismal diatal aortic arch Ann Thorac Surg 2001;701:1050-1052.
- Karck M, Chavan M, Khaladj N, Friedrich H, Hagl C, Haverich A. The frozen elephant trunk technique for the treatment of extensive thoracic aortic aneurysms: operative results and follow-up Eur J Cardiothorac Surg 2005;18:286-290.
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Abstract
Introduction
