Ann Thorac Surg 2009;88:22. doi:10.1016/j.athoracsur.2009.04.090
© 2009 The Society of Thoracic Surgeons
Original Articles: Adult Cardiac
Invited Commentary
Anthony J. Rousou, MD
Department of Cardiothoracic Surgery, Yale University School of Medicine, 330 Cedar St, FMB 128, New Haven, CT 06510
(Email: arousou{at}hotmail.com).
Dr Toda and colleagues present an interesting, but complicated, surgical approach for thoracic aortic aneurysmal disease [1]. They describe performing an aortic replacement using a four-branched graft beginning from the sinotubular junction to the mid-distal descending aorta with a single stage, using a long elephant trunk. There are several points I would like to make regarding this article. The first pertains to patient selection for this procedure. It would seem that only those patients with aortic arch disease extending to the distal descending aorta would require a "long elephant trunk" (LET). The greatest risk in using a long elephant trunk is of course spinal cord ischemia (SCI), and the authors did show a significant SCI rate of 8.1% (9 patients with 4 of them being permanent). Only 27 patients (24%) had disease that extended to the distal descending aorta. The remainder of patients had disease limited to the ascending aorta and arch (35%), or arch to the proximal descending aorta (41%). It seems that an LET would be unnecessary in these patients, and rather that a traditional arch replacement or "short" elephant trunk would suffice without the increased risk of SCI associated with an increased length of the elephant trunk. The authors confirmed this increased risk of SCI by univariate analysis showing a lower level of extension of the LET (thoracic level 8.4 vs 7.5; p = 0.03) in the SCI patients. Second, the procedure is very complicated, likely to an unnecessary degree. The article details selective cerebral perfusion (SCP) through a bilateral axillary cannulation and separate cannulation of the left carotid artery (LCA). We have found that deep hypothermic circulatory arrest alone provides excellent neuroprotection without the added complexity and danger of multiple arterial cannulations for SCP. The authors do acknowledge the embolic risk associated with direct cannulation of the arch vessels. In very difficult arch reconstructions that are likely to require greater than 45 minutes of circulatory arrest, we use selective antegrade cerebral perfusion through the right axillary cannulation site alone with excellent results. In addition to the bilateral axillary and LCA cannulations, the procedure calls for femoral cannulation to flush the descending aorta and grasp the distal end of the elephant trunk. The final question I would raise is whether the authors should consider doing the distal anastamosis between the LCA and the left subclavian artery. This technique makes the distal anastamosis much easier and faster, and it has been proven to be a safe alternative.
Toda and associates [1] are to be congratulated on excellent results obtained in a very difficult patient population. Although their results were excellent, the approach they describe for aortic arch aneurysm repair may not be suitable for all patients with this pathology, and perhaps this may be overly complicated for many patients and surgeons.
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References
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- Toda K, Taniguchi K, Masai T, Takahashi T, Kuki S, Sawa Y, Osaka Cardiac Surgery Research (OSCAR) Group Arch aneurysm repair with long elephant trunk: a 10-year experience in 111 patients Ann Thorac Surg 2009;88:16-22.[Abstract/Free Full Text]
Related Article
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Arch Aneurysm Repair With Long Elephant Trunk: A 10-Year Experience in 111 Patients
- Koichi Toda, Kazuhiro Taniguchi, Takafumi Masai, Toshiki Takahashi, Satoru Kuki, Yoshiki Sawa Osaka Cardiac Surgery Research (OSCAR) Group
Ann. Thorac. Surg. 2009 88: 16-22.
[Abstract]
[Full Text]
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