doi:10.1510/mmcts.2006.001925
Total arch replacement: technique of separate reimplantation of epi-aortic vessels Teruhisa Kazui* First Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu 431-3192, Japan Antegrade selective cerebral perfusion (SCP) with moderate hypothermia is the method of brain protection during aortic arch repair requiring a circulatory arrest longer than 30 min at our institute. It facilitates the total arch replacement using the aortic arch branched graft, and results in acceptable mortality and morbidity for arch aneurysm or dissection.
Keywords: Antegrade selective cerebral perfusion; Total arch replacement; Aortic arch branched graft Introduction In 1957, Dr DeBakey and colleagues first applied antegrade selective cerebral perfusion (SCP) as a cerebral protection method in arch aneurysm surgery w1x. But the normothermic high flow and high pressure SCP resulted in a rather high incidence of cerebral complication. The technique was, therefore, abandoned after that. Since then, several reports have been published regarding the modification of SCP including perfusion volume, pressure, site and temperature with varying surgical outcomes (Table 1, w1–7x). In 1986, we modified this technique to a moderately hypothermic, low flow and low pressure perfusion w6x.
Surgical technique Operative approach The operation is usually performed through median sternotomy with extensions of the incision to both supraclavicular regions. This approach allows us to * Corresponding author: Tel.: q81-53-435-2276; fax: q81-53-4352272 E-mail: [email protected] 䉷 2007 European Association for Cardio-thoracic Surgery
reach the descending aorta up to 5 cm distal to the origin of the left subclavian artery. If the aneurysm is large enough in size, the descending aorta at the level of the tracheal bifurcation (T6) can be reached. Cardiopulmonary bypass Cardiopulmonary bypass (CPB) is established by cannulating the ascending aorta or the right axillary artery, when necessary, for arterial inflow, and the right atrium using a single two-stage cannula for venous drainage. After SCP is established, the left ventricular vent is inserted through the right superior pulmonary vein. Myocardial protection is provided by both antegrade and retrograde blood cardioplegia. Epiaortic echo scanning and transesophageal echocardiography are routinely performed to select the site of arterial cannulation. If the ascending aorta is free from atherosclerotic debris, it is the preferred site for arterial cannulation. If the ascending aorta is found to be inappropriate because of the presence of atherosclerotic debris, the alternative site for arterial cannulation is the right axillary artery. An 8-mm Dacron graft is sutured to this artery in an end-to-side fashion. 1
T. Kazui / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2006.001925 Table 1. Antegrade selective cerebral perfusion. 1957 1968 1969 1979 1986 1989 1991
DeBakey w1x Bloodwell w2x Pearce w3x Crawford w4x Frist w5x Kazui w6x Bachet w7x
Normothermic high-flow, high-pressure IA and LCCA perfusion IA, LCCA, LAx perfusion using 3 pumps RAxA, LCCA, LAxA perfusion using a single pump Normothermic low-flow, low-pressure IA and LCCA perfusion Unilateral cerebral perfusion (26–288C) Hypothermic (22–258C) IA and LCCA perfusion Cold cerebroplegia (6–128C), IA and LCCA perfusion
IA: Innominate artery, LCCA: Left common carotid artery, LAxA: Left axillary artery, RAxA: Right axillary artery.
Photo 1. SCP cannula.
Selective cerebral perfusion cannula For antegrade SCP, a newly developed flexible perfusion cannula (Fuji System Corporation, Tokyo, Japan) is used (Photo 1). This cannula has three lumina: one for blood perfusion, one for balloon inflation, and one for pressure monitoring. A balloon at the tip prevents slippage of the cannula when inflated after cannulation of the arch vessels. The cannula, because of its flexible metallic support, can be bent manually at the desired angle without causing any luminal compromise. This property of the cannula allows the surgeon to place them toward the patient’s head side so that they do not obscure the operative field. Cannula sizes used are 18 F for innominate artery perfusion and 14 F for left common carotid artery perfusion. Antegrade selective cerebral perfusion protocol In principle, the bilateral 2-arch vessel perfusion technique is used (Schematic 1) w8,9x. Both innominate and left common carotid arteries are perfused at a rate of 10 ml/kg/min at a rectal temperature of 258C by a single pump separate from the systemic circulation. The left subclavian artery is kept cross-clamped during SCP. The right radial arterial pressure as well as the bilateral catheter tip pressure 2
Schematic 1. SCP: Two-arch vessel perfusion (innominate artery, left common carotid artery).
are adjusted to around 40 mmHg to regulate the perfusion pressure. Arterial blood pH is managed according to the a-stat strategy during CPB. If the right axillary artery is used for arterial cannulation, systemic perfusion is started through the graft sutured to this artery together with the femoral artery. After cooling the patient, the innominate artery is clamped proximally, the left common carotid artery is cannulated, and both right axillary and left common carotid arteries are perfused as SCP (Schematic 2). Three-arch-vessel perfusion (Schematic 3), that is additional left subclavian artery perfusion is performed in selected patients, who have occlusion of right vertebral artery, dominant left vertebral artery, and lack of efficient intracranial arterial communication to avoid the risk of vertebrobasilar artery insufficiency. Four-branched aortic arch grafts Four-branched aortic arch grafts used for the separated graft technique are now commercially available (Photo 2) (MMCTSLink 133). Three branches are used for arch-vessel reimplantation, and one is used for
T. Kazui / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2006.001925
Photo 2. Commercially available four-branched arch graft. Schematic 2. SCP: Two-arch vessel perfusion (right axillary artery, left common carotid artery).
Schematic 4. Separated graft technique.
Schematic 3. SCP: Three-arch vessel perfusion (innominate artery, left common carotid artery, left subclavian artery).
antegrade systemic perfusion after the distal graft anastomosis is complete. Separated graft technique Schematic 4 shows the separated graft technique which is now our preferred surgical procedure w10,11x. Under SCP with systemic circulatory arrest, the distal end of the arch graft is sutured to the descending aortic stump. Antegrade perfusion is started from the side branch of the graft. The left subclavian artery is sutured to the third branch of the arch graft. Then rewarming by CPB is started. The proximal end of the arch graft is sutured to the ascending aortic stump. Then the innominate and the left common carotid
arteries are sutured to the corresponding branches of the arch graft. MR angiogram (Photo 3) shows the completed reconstruction. The details of the operative procedure are shown in Videos 1–17. Separated graft technique for acute type-A dissection The separated graft technique is also safely used in patients with acute type-A dissection w12x. The surgical technique is essentially similar to that in atherosclerotic aneurysm except for the obliteration of the proximal and distal false lumen and elephant trunk technique in which, a short segment of graft is placed in the true lumen of the descending aorta (Schematic 5). Advantages of separated graft technique Separated graft technique presents several advantages over the en bloc technique or island technique, in 3
T. Kazui / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2006.001925
Video 3. Cannulating the arch vessels. The innominate artery is cannulated through the arteriectomy under direct vision and is secured with tourniquet. The left common carotid artery is cannulated in a similar fashion. These cannulae are placed toward the patient’s head side, so that they do not obscure the operative field.
Photo 3. Postoperative MR angiogram of a patient who received total arch replacement with the separated graft technique.
Video 1. Cross-clamping the arch-vessel. The patient is placed on the CPB, and cooled down to a rectal temperature of 258C. Systemic circulation is arrested, and the arch vessels are cross-clamped with bulldog clamp.
Video 4. Transecting the left subclavian artery. The incision is extended to the proximal descending aorta. The left subclavian artery is transected distal to its origin.
Video 5. Preparing the distal aortic stump. Intramural hematoma is removed from aneurysm sac. The proximal descending aorta at the lesser curvature is sharply isolated from the esophagus and is resected. The longitudinal incision is extended to the level of descending aorta distal to the aneurysm, and then the aorta is completely transected. The length between the origin of left subclavian artery and the aortic stump is 8 cm in this case. This is the aortic stump.
Video 2. Incising the aorta. Incision is made on the ascending aorta, and is extended to the orifice of the innominate artery. The artery is transected distal to its origin. The orifice of the artery is irrigated with saline solution.
which the arch-vessels are reimplanted to the side hole of the graft (Schematic 6) w13x. 4
Video 6. Trimming the arch graft. The distal part of the aortic arch graft is trimmed to an appropriate length.
T. Kazui / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2006.001925
Video 7. Performing distal graft anastomosis. The distal side of the arch graft is then sutured to the stump of the descending aorta using 3-0 monofilament suture with a Teflon felt strip reinforced on the aorta. Once the descending aorta is completely transected, and the intercostal and bronchial arteries which are located at the resected segment are ligated, the aortic stump can be easily pulled up to the operative field. Care must be taken to perform a meticulous through and through anastomosis.
Video 11. Transecting the ascending aorta. The ascending aorta is completely transected just above the ST junction.
Video 12. Trimming the arch graft. The proximal side of the arch graft is trimmed to an appropriate length. Video 8. Checking the distal graft anastomosis. Antegrade systemic perfusion is started through the side branch, and the distal graft anastomosis is carefully checked.
Video 13. Performing proximal graft anastomosis. The graft is sutured to the stump of the ascending aorta using a running 3-0 monofilament suture with a Teflon felt strip reinforced on the aorta. Video 9. Reinforcing the distal graft anastomosis. The Teflon felt strip is now fixed at the graft anastomosis, and fibrin glue is applied to the suture line. This Teflon felt is then placed around the anastomosis, and secured tightly.
Video 14. Removing the air. Air is removed from the graft, and coronary circulation is started. Air vent needle is inserted into the graft. Video 10. Reconstructing the left subclavian artery. The left subclavian artery is sutured to the third branch of the arch graft. Following this, rewarming by extracorporeal circulation is started.
They include: 1. arch vessel anastomoses are performed at the intact distal arteries where they are free from atherosclerotic debris or dissection.
2. pathological portion of the aortic arch can be completely resected in a Marfan’s patient. 3. bleeding from the site of the arch vessels anastomoses can be easily controlled. 4. antegrade systemic perfusion through the arch graft prevents the retrograde embolization or organ malperfusion. 5
T. Kazui / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2006.001925
Video 15. Reconstructing the innominate artery. The innominate artery is sutured to the first branch of the graft. The cannula is removed, and cerebral perfusion volume is reduced to half the original one.
Schematic 6. En bloc technique.
Video 16. Reconstructing the left common carotid artery. The left common carotid artery is sutured to the second branch of the graft in a similar fashion.
thermic CPB and antegrade SCP between January 1986 and March 2006. Etiologies of the aortic disease were acute dissection in 27% of the patients, chronic dissection in 21%, and non-dissection in 52%. Emergency operation was performed in 29% of the patients for rupture of aneurysm or acute dissection. As for the extent of aortic replacement, overall total arch replacement was performed in 421 patients (89%), and simultaneous descending aortic replacement in 176 (37%) patients.
Video 17. Completing the operation. Thus, the operation is completed.
One hundred and sixty-seven patients (35%) received 182 concomitant procedures including CABG, composite graft replacement, AVR, etc. Overall in-hospital mortality was 9.3%, but it significantly decreased to 4.1% in the recent 268 patients operated on since 1997, including the emergency cases. The overall postoperative temporary and permanent neurological dysfunctions were 4.7% and 3.2%, respectively. Mean SCP time was 88 min in this series. There was no significant correlation between SCP time and in-hospital mortality or postoperative neurological dysfunction.
References
Schematic 5. Separated graft technique for acute type A aortic dissection.
Results Four hundred and seventy-four patients underwent surgery for arch aneurysm or dissection using hypo6
w1x DeBakey ME, Crawford ES, Cooley DA, Morris GC Jr. Successful resection of fusiform aneurysm of aortic arch with replacement by homograft. Surg Gynecol Obstet 1957;105:657–664. w2x Bloodwell RD, Hallman GL, Cooley DA. Total replacement of the aortic arch and the ‘‘subclavian steal’’ phenomenon. Ann Thorac Surg 1968;5:236–245.
T. Kazui / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2006.001925 w3x Pearce CW, Weichert RF 3rd, del Real RE. Aneurysms of aortic arch. Simplified technique for excision and prosthetic replacement. J Thorac Cardiovasc Surg 1969;58:886–890. w4x Crawford ES, Saleh SA, Schuessler JS. Treatment of aneurysm of transverse aortic arch. J Thorac Cardiovasc Surg 1979;78:383–393. w5x Frist WH, Baldwin JC, Starnes VA, Stinson EB, Oyer PE, Miller DC, Jamieson SW, Mitchell RS, Shumway NE. A reconsideration of cerebral perfusion in aortic arch replacement. Ann Thorac Surg 1986;42:273–281. w6x Kazui T, Inoue N, Komatsu S. Surgical treatment of aneurysms of the transverse aortic arch. J Cardiovasc Surg (Torino) 1989;30:402–406. w7x Bachet J, Guilmet D, Goudot B, Termignon JL, Teodori G, Dreyfus G, Brodaty D, Dubois C, Delentdecker P. Cold cerebroplegia. A new technique of cerebral protection during operations on the transverse aortic arch. J Thorac Cardiovasc Surg 1991;102:85–93. w8x Kazui T, Inoue N, Yamada O, Komatsu S. Selective cerebral perfusion during operation for aneurysms of the aortic arch: a reassessment. Ann Thorac Surg 1992;53:109–114.
w9x Kazui T, Kimura N, Yamada O, Komatsu S. Surgical outcome of aortic arch aneurysms using selective cerebral perfusion. Ann Thorac Surg 1994;57:904–911. w10x Kazui T, Washiyama N, Bashar AHM, Terada H, Yamashita K, Takinami M, Tamiya Y. Total arch replacement using aortic arch branched grafts with the aid of antegrade selective cerebral perfusion. Ann Thorac Surg 2000;70:3–9. w11x Kazui T, Washiyama N, Bashar AHM, Terada H, Yamashita K, Takinami M. Improved results of atherosclerotic arch aneurysm operations with a refined technique. J Thorac Cardiovasc Surg 2001;121:491–499. w12x Kazui T, Washiyama N, Bashar AHM, Terada H, Yamashita K, Takinami M, Tamiya Y. Extended total arch replacement for acute type A aortic dissection: experience with seventy patients. J Thorac Cardiovasc Surg 2000;119:558–565. w13x Di Eusanio M, Schepens MAAM, Morshuis WJ, Dossche KM, Kazui T, Ohkura K, Washiyama N, Di Bartolomeo R, Pacini D, Pierangeli A. Separate grafts or en bloc anastomosis for arch vessels reimplantation to the aortic arch. Ann Thorac Surg 2004;77:2021–2028.
7
Total arch replacement: technique of separate reimplantation of epi-aortic vessels Teruhisa Kazui* First Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu 431-3192, Japan Antegrade selective cerebral perfusion (SCP) with moderate hypothermia is the method of brain protection during aortic arch repair requiring a circulatory arrest longer than 30 min at our institute. It facilitates the total arch replacement using the aortic arch branched graft, and results in acceptable mortality and morbidity for arch aneurysm or dissection.
Keywords: Antegrade selective cerebral perfusion; Total arch replacement; Aortic arch branched graft Introduction In 1957, Dr DeBakey and colleagues first applied antegrade selective cerebral perfusion (SCP) as a cerebral protection method in arch aneurysm surgery w1x. But the normothermic high flow and high pressure SCP resulted in a rather high incidence of cerebral complication. The technique was, therefore, abandoned after that. Since then, several reports have been published regarding the modification of SCP including perfusion volume, pressure, site and temperature with varying surgical outcomes (Table 1, w1–7x). In 1986, we modified this technique to a moderately hypothermic, low flow and low pressure perfusion w6x.
Surgical technique Operative approach The operation is usually performed through median sternotomy with extensions of the incision to both supraclavicular regions. This approach allows us to * Corresponding author: Tel.: q81-53-435-2276; fax: q81-53-4352272 E-mail: [email protected] 䉷 2007 European Association for Cardio-thoracic Surgery
reach the descending aorta up to 5 cm distal to the origin of the left subclavian artery. If the aneurysm is large enough in size, the descending aorta at the level of the tracheal bifurcation (T6) can be reached. Cardiopulmonary bypass Cardiopulmonary bypass (CPB) is established by cannulating the ascending aorta or the right axillary artery, when necessary, for arterial inflow, and the right atrium using a single two-stage cannula for venous drainage. After SCP is established, the left ventricular vent is inserted through the right superior pulmonary vein. Myocardial protection is provided by both antegrade and retrograde blood cardioplegia. Epiaortic echo scanning and transesophageal echocardiography are routinely performed to select the site of arterial cannulation. If the ascending aorta is free from atherosclerotic debris, it is the preferred site for arterial cannulation. If the ascending aorta is found to be inappropriate because of the presence of atherosclerotic debris, the alternative site for arterial cannulation is the right axillary artery. An 8-mm Dacron graft is sutured to this artery in an end-to-side fashion. 1
T. Kazui / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2006.001925 Table 1. Antegrade selective cerebral perfusion. 1957 1968 1969 1979 1986 1989 1991
DeBakey w1x Bloodwell w2x Pearce w3x Crawford w4x Frist w5x Kazui w6x Bachet w7x
Normothermic high-flow, high-pressure IA and LCCA perfusion IA, LCCA, LAx perfusion using 3 pumps RAxA, LCCA, LAxA perfusion using a single pump Normothermic low-flow, low-pressure IA and LCCA perfusion Unilateral cerebral perfusion (26–288C) Hypothermic (22–258C) IA and LCCA perfusion Cold cerebroplegia (6–128C), IA and LCCA perfusion
IA: Innominate artery, LCCA: Left common carotid artery, LAxA: Left axillary artery, RAxA: Right axillary artery.
Photo 1. SCP cannula.
Selective cerebral perfusion cannula For antegrade SCP, a newly developed flexible perfusion cannula (Fuji System Corporation, Tokyo, Japan) is used (Photo 1). This cannula has three lumina: one for blood perfusion, one for balloon inflation, and one for pressure monitoring. A balloon at the tip prevents slippage of the cannula when inflated after cannulation of the arch vessels. The cannula, because of its flexible metallic support, can be bent manually at the desired angle without causing any luminal compromise. This property of the cannula allows the surgeon to place them toward the patient’s head side so that they do not obscure the operative field. Cannula sizes used are 18 F for innominate artery perfusion and 14 F for left common carotid artery perfusion. Antegrade selective cerebral perfusion protocol In principle, the bilateral 2-arch vessel perfusion technique is used (Schematic 1) w8,9x. Both innominate and left common carotid arteries are perfused at a rate of 10 ml/kg/min at a rectal temperature of 258C by a single pump separate from the systemic circulation. The left subclavian artery is kept cross-clamped during SCP. The right radial arterial pressure as well as the bilateral catheter tip pressure 2
Schematic 1. SCP: Two-arch vessel perfusion (innominate artery, left common carotid artery).
are adjusted to around 40 mmHg to regulate the perfusion pressure. Arterial blood pH is managed according to the a-stat strategy during CPB. If the right axillary artery is used for arterial cannulation, systemic perfusion is started through the graft sutured to this artery together with the femoral artery. After cooling the patient, the innominate artery is clamped proximally, the left common carotid artery is cannulated, and both right axillary and left common carotid arteries are perfused as SCP (Schematic 2). Three-arch-vessel perfusion (Schematic 3), that is additional left subclavian artery perfusion is performed in selected patients, who have occlusion of right vertebral artery, dominant left vertebral artery, and lack of efficient intracranial arterial communication to avoid the risk of vertebrobasilar artery insufficiency. Four-branched aortic arch grafts Four-branched aortic arch grafts used for the separated graft technique are now commercially available (Photo 2) (MMCTSLink 133). Three branches are used for arch-vessel reimplantation, and one is used for
T. Kazui / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2006.001925
Photo 2. Commercially available four-branched arch graft. Schematic 2. SCP: Two-arch vessel perfusion (right axillary artery, left common carotid artery).
Schematic 4. Separated graft technique.
Schematic 3. SCP: Three-arch vessel perfusion (innominate artery, left common carotid artery, left subclavian artery).
antegrade systemic perfusion after the distal graft anastomosis is complete. Separated graft technique Schematic 4 shows the separated graft technique which is now our preferred surgical procedure w10,11x. Under SCP with systemic circulatory arrest, the distal end of the arch graft is sutured to the descending aortic stump. Antegrade perfusion is started from the side branch of the graft. The left subclavian artery is sutured to the third branch of the arch graft. Then rewarming by CPB is started. The proximal end of the arch graft is sutured to the ascending aortic stump. Then the innominate and the left common carotid
arteries are sutured to the corresponding branches of the arch graft. MR angiogram (Photo 3) shows the completed reconstruction. The details of the operative procedure are shown in Videos 1–17. Separated graft technique for acute type-A dissection The separated graft technique is also safely used in patients with acute type-A dissection w12x. The surgical technique is essentially similar to that in atherosclerotic aneurysm except for the obliteration of the proximal and distal false lumen and elephant trunk technique in which, a short segment of graft is placed in the true lumen of the descending aorta (Schematic 5). Advantages of separated graft technique Separated graft technique presents several advantages over the en bloc technique or island technique, in 3
T. Kazui / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2006.001925
Video 3. Cannulating the arch vessels. The innominate artery is cannulated through the arteriectomy under direct vision and is secured with tourniquet. The left common carotid artery is cannulated in a similar fashion. These cannulae are placed toward the patient’s head side, so that they do not obscure the operative field.
Photo 3. Postoperative MR angiogram of a patient who received total arch replacement with the separated graft technique.
Video 1. Cross-clamping the arch-vessel. The patient is placed on the CPB, and cooled down to a rectal temperature of 258C. Systemic circulation is arrested, and the arch vessels are cross-clamped with bulldog clamp.
Video 4. Transecting the left subclavian artery. The incision is extended to the proximal descending aorta. The left subclavian artery is transected distal to its origin.
Video 5. Preparing the distal aortic stump. Intramural hematoma is removed from aneurysm sac. The proximal descending aorta at the lesser curvature is sharply isolated from the esophagus and is resected. The longitudinal incision is extended to the level of descending aorta distal to the aneurysm, and then the aorta is completely transected. The length between the origin of left subclavian artery and the aortic stump is 8 cm in this case. This is the aortic stump.
Video 2. Incising the aorta. Incision is made on the ascending aorta, and is extended to the orifice of the innominate artery. The artery is transected distal to its origin. The orifice of the artery is irrigated with saline solution.
which the arch-vessels are reimplanted to the side hole of the graft (Schematic 6) w13x. 4
Video 6. Trimming the arch graft. The distal part of the aortic arch graft is trimmed to an appropriate length.
T. Kazui / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2006.001925
Video 7. Performing distal graft anastomosis. The distal side of the arch graft is then sutured to the stump of the descending aorta using 3-0 monofilament suture with a Teflon felt strip reinforced on the aorta. Once the descending aorta is completely transected, and the intercostal and bronchial arteries which are located at the resected segment are ligated, the aortic stump can be easily pulled up to the operative field. Care must be taken to perform a meticulous through and through anastomosis.
Video 11. Transecting the ascending aorta. The ascending aorta is completely transected just above the ST junction.
Video 12. Trimming the arch graft. The proximal side of the arch graft is trimmed to an appropriate length. Video 8. Checking the distal graft anastomosis. Antegrade systemic perfusion is started through the side branch, and the distal graft anastomosis is carefully checked.
Video 13. Performing proximal graft anastomosis. The graft is sutured to the stump of the ascending aorta using a running 3-0 monofilament suture with a Teflon felt strip reinforced on the aorta. Video 9. Reinforcing the distal graft anastomosis. The Teflon felt strip is now fixed at the graft anastomosis, and fibrin glue is applied to the suture line. This Teflon felt is then placed around the anastomosis, and secured tightly.
Video 14. Removing the air. Air is removed from the graft, and coronary circulation is started. Air vent needle is inserted into the graft. Video 10. Reconstructing the left subclavian artery. The left subclavian artery is sutured to the third branch of the arch graft. Following this, rewarming by extracorporeal circulation is started.
They include: 1. arch vessel anastomoses are performed at the intact distal arteries where they are free from atherosclerotic debris or dissection.
2. pathological portion of the aortic arch can be completely resected in a Marfan’s patient. 3. bleeding from the site of the arch vessels anastomoses can be easily controlled. 4. antegrade systemic perfusion through the arch graft prevents the retrograde embolization or organ malperfusion. 5
T. Kazui / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2006.001925
Video 15. Reconstructing the innominate artery. The innominate artery is sutured to the first branch of the graft. The cannula is removed, and cerebral perfusion volume is reduced to half the original one.
Schematic 6. En bloc technique.
Video 16. Reconstructing the left common carotid artery. The left common carotid artery is sutured to the second branch of the graft in a similar fashion.
thermic CPB and antegrade SCP between January 1986 and March 2006. Etiologies of the aortic disease were acute dissection in 27% of the patients, chronic dissection in 21%, and non-dissection in 52%. Emergency operation was performed in 29% of the patients for rupture of aneurysm or acute dissection. As for the extent of aortic replacement, overall total arch replacement was performed in 421 patients (89%), and simultaneous descending aortic replacement in 176 (37%) patients.
Video 17. Completing the operation. Thus, the operation is completed.
One hundred and sixty-seven patients (35%) received 182 concomitant procedures including CABG, composite graft replacement, AVR, etc. Overall in-hospital mortality was 9.3%, but it significantly decreased to 4.1% in the recent 268 patients operated on since 1997, including the emergency cases. The overall postoperative temporary and permanent neurological dysfunctions were 4.7% and 3.2%, respectively. Mean SCP time was 88 min in this series. There was no significant correlation between SCP time and in-hospital mortality or postoperative neurological dysfunction.
References
Schematic 5. Separated graft technique for acute type A aortic dissection.
Results Four hundred and seventy-four patients underwent surgery for arch aneurysm or dissection using hypo6
w1x DeBakey ME, Crawford ES, Cooley DA, Morris GC Jr. Successful resection of fusiform aneurysm of aortic arch with replacement by homograft. Surg Gynecol Obstet 1957;105:657–664. w2x Bloodwell RD, Hallman GL, Cooley DA. Total replacement of the aortic arch and the ‘‘subclavian steal’’ phenomenon. Ann Thorac Surg 1968;5:236–245.
T. Kazui / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2006.001925 w3x Pearce CW, Weichert RF 3rd, del Real RE. Aneurysms of aortic arch. Simplified technique for excision and prosthetic replacement. J Thorac Cardiovasc Surg 1969;58:886–890. w4x Crawford ES, Saleh SA, Schuessler JS. Treatment of aneurysm of transverse aortic arch. J Thorac Cardiovasc Surg 1979;78:383–393. w5x Frist WH, Baldwin JC, Starnes VA, Stinson EB, Oyer PE, Miller DC, Jamieson SW, Mitchell RS, Shumway NE. A reconsideration of cerebral perfusion in aortic arch replacement. Ann Thorac Surg 1986;42:273–281. w6x Kazui T, Inoue N, Komatsu S. Surgical treatment of aneurysms of the transverse aortic arch. J Cardiovasc Surg (Torino) 1989;30:402–406. w7x Bachet J, Guilmet D, Goudot B, Termignon JL, Teodori G, Dreyfus G, Brodaty D, Dubois C, Delentdecker P. Cold cerebroplegia. A new technique of cerebral protection during operations on the transverse aortic arch. J Thorac Cardiovasc Surg 1991;102:85–93. w8x Kazui T, Inoue N, Yamada O, Komatsu S. Selective cerebral perfusion during operation for aneurysms of the aortic arch: a reassessment. Ann Thorac Surg 1992;53:109–114.
w9x Kazui T, Kimura N, Yamada O, Komatsu S. Surgical outcome of aortic arch aneurysms using selective cerebral perfusion. Ann Thorac Surg 1994;57:904–911. w10x Kazui T, Washiyama N, Bashar AHM, Terada H, Yamashita K, Takinami M, Tamiya Y. Total arch replacement using aortic arch branched grafts with the aid of antegrade selective cerebral perfusion. Ann Thorac Surg 2000;70:3–9. w11x Kazui T, Washiyama N, Bashar AHM, Terada H, Yamashita K, Takinami M. Improved results of atherosclerotic arch aneurysm operations with a refined technique. J Thorac Cardiovasc Surg 2001;121:491–499. w12x Kazui T, Washiyama N, Bashar AHM, Terada H, Yamashita K, Takinami M, Tamiya Y. Extended total arch replacement for acute type A aortic dissection: experience with seventy patients. J Thorac Cardiovasc Surg 2000;119:558–565. w13x Di Eusanio M, Schepens MAAM, Morshuis WJ, Dossche KM, Kazui T, Ohkura K, Washiyama N, Di Bartolomeo R, Pacini D, Pierangeli A. Separate grafts or en bloc anastomosis for arch vessels reimplantation to the aortic arch. Ann Thorac Surg 2004;77:2021–2028.
7
