Ann Thorac Surg 2008;86:1721. doi:10.1016/j.athoracsur.2008.05.024
© 2008 The Society of Thoracic Surgeons
Correspondence
Reinforcement of Anastomosis in Aortic Dissection Surgery
Roberto Gaeta, Prof,
Salvatore Lentini, MD,
Fabrizio Tancredi, MD,
Francesco Monaco, MD
Cardiac Surgery Unit, Policlinic Hospital University of Messina, Department of Cardiac Surgery, Via Consolare Valeria, Messina, 98100 Italy
(Email: salvolentini{at}alice.it).
To the Editor:
We read with great interest the article of Nakamura and colleagues [1]. The authors report hemolytic anemia caused by anastomotic stenosis after surgical treatment for aortic dissection in which internal and external Teflon felt strips (DuPont, Wilmington, DE) were used for reinforcement of the aortic stump. It is interesting that the same authors of this article already described this phenomenon in the past [2]. As they pointed out the main problem is the stenosis of the anastomotic area. The genesis of this pattern is probably due both to the inflammatory response due to gelatin-resorcinol-formaldehyde (Cardial Technopole, Sainte-Etienne, France) glue [3] and proper sizing by using a Teflon strip.
Many years ago, Doty and Arcidi [4] presented an elegant technical review of many methods for correct graft sizing in aortic valve sparing operations to this journal. This issue is particularly relevant in two instances. The first one is in order to re-suspend the native aortic valve inside a graft as for David and colleagues' [5] procedure. The second one, in presence of a dissected ascending aorta and aortic root, where as a main pattern, a dilated aorta is commonly found. In this case, the procedure of valve re-suspension should be associated to an accurate analysis of the valve [6]. It is not infrequent in our practice to do a plasty of the valve at commissural level and re-suspension of the commissures.
On this ground we recently described an easy method to reinforce the anastomosis and avoid any potential under-sizing [7]. A 3-mm to 4-mm annular segment of the chosen tube graft prosthesis is cut away. This first piece of graft is placed inside the aorta at anastomotic level. A second piece of graft, same width, but open in a "C" shape is placed outside the aorta. These two pieces, one inside and the other outside the aortic wall, are held in place by two whip stitches, which are used to construct the anastomosis between aorta and tube graft. The gap of the "C"-shaped segment is eventually filled by another small piece of annular graft. In our experience, it is very difficult to undersize the anastomosis and any bulky presence of the Teflon felt (DuPont) is avoided. This simple technique may help to prevent the phenomenon described by Nakamura and colleagues [1].
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References
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- Nakamura Y, Ogino H, Matsuda H, Minatoya K, Sasaki H, Kitamura S. Hemolytic anemia after operation for aortic dissection using Teflon felt strips Ann Thorac Surg 2008;85:1784-1787.[Abstract/Free Full Text]
- Matsuura K, Ogino H, Minatoya K, Sasaki H. Aortic stenosis caused by the felt strip used in repair for acute aortic dissection Interact Cardiovasc Thorac Surg 2004;42:41-43.
- Bachet J, Gigou F, Laurian C, Bical O, Goudot B, Guilmet D. Four year clinical experience with the gelatin-resorcine-formol biological glue in acute aortic dissection J Thorac Cardiovasc Surg 1982;83:212-217.[Medline]
- Doty DB, Arcidi JM. Methods for graft size selection in aortic valve-sparing operations Ann Thorac Surg 2000;69:648-650.[Abstract/Free Full Text]
- David TE, Feindel CM, Bos J. Repair of aortic valve in patients with aortic insufficency and aortic root aneurysm J Thorac Cardiovasc Surg 1995;109:345-352.[Abstract/Free Full Text]
- El Khoury G, Vanoverschelde JL, Glineur D, et al. Repair of aortic valve prolapse: experience with 44 patients Eur J Cardiothorac Surg 2004;26:628-633.[Abstract/Free Full Text]
- Gaeta R, Lentini S, Tancredi F, Monaco F, Savasta M. Surgery for acute aortic dissection: an easy and cheap method to reinforce the anastomosis J Card Surg 2008Sep 12. [Epub ahead of print].
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