- Letter to the Editor
- Open Access
- Open Peer Review
Modification in aortic arch replacement surgery
© The Author(s). 2018
- Received: 2 July 2017
- Accepted: 13 December 2017
- Published: 12 February 2018
We modified the conventional aortic arch replacement procedure to avoid circulation arrest and a prolonged extracorporeal circulation time, especially in cases of acute aortic dissection. We herein present our experience with a modified branch-first approach to acute aortic dissection, with anastomosis of the supra aortic vessels prior to commencing cardiopulmonary bypass.
Since 2012, 41 patients (aortic dissection, 36; arch aneurysm, 5) have undergone the modified procedure. Procedurally, the implanted graft was used as a landing zone for second-stage endovascular stent-graft deployment intended to manage the residual descending dissection. Antegrade and retrograde systemic perfusion was instituted during cardioplegic arrest. The brain was actively perfused via the graft throughout the procedure.
Arch replacement surgery could generally be completed within approximately 4 h. During a 2-year period of aortic dissection or arch aneurysm treatment, only four anastomoses were required during the first stage of operation: two in the aorta, and one each in the innominate and left common carotid arteries. No patient died of surgical causes, and no stent grafts were deployed into the false lumen, a characteristic of procedures using traditionally antegrade deployment.
We recommend that our procedure for acute aortic dissection be performed in two stages (graft replacement first and stent graft deployment second), particularly for patients underwent preoperative hypotesion. If malperfusion syndrome still exists after graft replacement, stent graft should be deployed in one stage. The arch aneurysm can be treated in one stage because there is no concern about false lumen deployment.
- Hybrid procedure
- Debranch procedure
- Aortic arch replacement
- Aortic dissection type A
We modified the conventional aortic arch replacement procedure, especially for acute aortic dissection, to avoid circulation arrest and a prolonged extracorporeal circulation time, which have been identified as independent risk factors for morbidity and mortality [1, 2].
Preparation: We recommend performing this procedure in a hybrid operation room. Bilateral cerebral oxygen saturation and invasive artery pressure in the bilateral upper limbs were monitored continuously during the operation.
Operation steps (Additional file 1: Video 1)
After performing sternotomy and opening the pericardium, the tissues were dissected free as much as possible to expose the aortic arch and supra-arch branches. The adventitia was reserved as much as possible to facilitate suturing of the fragile arteries in an acute setting. The patient was subsequently heparinised.
Video 1 showed the procedural steps of simplified arch replacement approach. (MP4 286720 kb)
We used a fine paediatric vascular clamp, such as a Pilling clamp 354,486, to fully close the left carotid artery (LCA) and thus avoid secondary injury to the intima. We usually sutured the intima to the adventitia, which had been severely torn, using a 7–0 prolene suture and mattress-suturing and added a pericardial strip outside the carotid artery. Next, we completed the end-to-side anastomosis between the branch and LCA using a 6–0 prolene suture.
We then measured the length of the second branch of the aortic graft (28 mm; Interguard, Maquet, France) and clipped it, and clamped and transected the innominate artery and trimmed the end to prepare for anastomosis. We anastomosed the graft branch and innominate artery in an end-to-end manner using a 5–0 prolene suture, and completed the end-to-side anastomosis between the branch and left common carotid artery. These end-to-side and end-to-end anastomoses are key to understanding how to actively perfuse the brain. Specifically, this method does not cause brain circulatory arrest of blood flow from the carotid to the innominate artery during the procedure, yet it allows the aorta to be clamped near the carotid artery. The proximal end of the innominate artery does not require suturing if the segment has been severely dissected; rather, clamping can be performed until the aorta is closed.
The left femoral artery was exposed and cannulated using a cannula connected to the cardiopulmonary bypass to yield retrograde artery perfusion. A hybrid operating room can confirm that the cannula has been placed in the true aortic lumen. We inserted a two-stage cannula in the right atrium, and established another artery cannula branched from the artery end of cardiopulmonary bypass using a Y-shaped connector to the perfusion branch of the graft. Accordingly, the aorta was perfused in both an antegrade and retrograde manner, which allowed adequate perfusion of the viscera, even in the presence of preoperative malperfusion syndrome. The cardiopulmonary bypass was established, and the blood was cooled to 28 °C.
Once the blood temperature reached 32 °C, the aorta was clamped near the left common carotid artery. The ascending aorta was opened, and cardioplegia fluid was perfused into the left and right coronary arteries to induce cardiac arrest. We trimmed the proximal end of the aorta and reinforced the aortic wall with two Dacron strip patches using the sandwich technique. The distal end of the aorta was treated in the same manner. The distal anastomosis of the aorta and graft was achieved with a 3–0 prolene suture, after which we released the clamp distal to the graft to determine whether any bleeding would occur. We found that it was safer and more efficient to wrap the anastomosis with a strip patch than to use sutures. The proximal anastomosis of the aorta with the graft was performed in the same manner.
Finally, the patient was rewarmed and the heart beat recovered. The root of the left common carotid artery was closed using a 5–0 prolene suture to prevent retrograde blood flow into the false lumen. From that point, the aortic dissection was changed from type A to type B. Extracorporeal circulation was restored in a stepwise manner to complete the procedure. Angiography revealed the remaining distal dissection. Endovascular repair was not immediately required except in cases of low perfusion syndrome or a threatened rupture.
Two weeks later, the patient returned to the operating room, where a femoral approach to expose the femoral artery was performed under local infiltration anaesthesia. Once the catheter reached the ascending aorta, a superstiff guidewire (Lunderquist, COOK, US) was introduced for stent graft deployment. Finally, a 20-cm-long stent graft (34 × 200 mm; Tag, GORE, US) was deployed near the second graft branch orifice.
Funded by the Science and technology projects of HaiNan social development, SF201420.
Availability of data and materials
The authors have no conflicts of interest as described by the Journal, and no conflicts of interest with any commercial organization and person upon preparing the manuscript.
Dr.Feng Gao is the designer of the technique, the main operator performed the procedure and the writer of the article. The others are the teammate attended in the surgery.
Ethics approval and consent to participate
Were admitted by ethics committee of Xiangya Haikou Hospital of Central South University.
Consent for publication
The authors have no competing interest with each other and with any commercial organization or person.
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