Aortic arch reconstruction utilizing a simple reversed graft trimming technique
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《血管的通路杂志》
Department of Thoracic and Cardiovascular Surgery/F24, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA
Abstract
We describe a simple method for ascending aorta and heimarch/arch reconstruction that reduces tension, avoids graft kinking, and provides optimal orientation for the proximal anastomosis.
Key Words: Anastomosis; Aortic surgery; Aortic arch
1. Introduction
The normal ascending aorta and aortic arch are smoothly curved with an inner contour that is shorter than the outer. After resection and replacement with a vascular prosthesis, graft kinking is a common issue. The result is often a suboptimal reconstruction.
The distal graft is beveled for anastomosis below the arch vessels. As typically described, the graft bevel is fashioned to accommodate the curve of the arch with the tongue of the graft pointed towards the patient's left side. The subsequent anastomosis proximally, either to the aorta or to an ascending graft, is then constructed in a manner that must take into consideration two opposing angles. Further graft beveling is often required. The consequence is frequently kinking, tension, or anterior displacement of the anastomosis. This latter circumstance would be particularly concerning in the event of re-sternotomy.
While appropriate graft length is critical in preventing such outcomes, it must be associated with a carefully fashioned distal anastomosis to ensure a good result. Several authors have proposed alternate beveling techniques to help avoid the aforementioned complications [1,2]. A curved vascular prosthesis has also been manufactured to address this issue [3].
We describe a simple graft trimming technique that affords appropriate orientation and, when associated with precise graft length, helps to avoid the potential hemodynamic consequences of kinking.
2. Technique
We utilize the right axillary artery and the ascending aorta as our preferred cannulation sites. Retrograde cerebral perfusion is used during the circulatory arrest period. After circulatory arrest is instituted, the aortic arch is resected back as required. Most often a hemiarch resection is performed, leaving the innominate artery and the left common carotid artery in continuity with the distal aorta. Selection of the vascular prosthesis is determined by the size of the proximal aorta. Distally, the graft is trimmed to accommodate the circumference of the distal opening and to allow the graft to have a straight course. This is guided by the appearance of the open distal aorta. The graft is trimmed to allow a straight rather than curved connection between the two ends of the aorta. Generally, the cut angle is between 30 and 60 degrees. The distal anastomosis is performed with the tongue of the graft directed towards the patient's right shoulder. Suturing is then begun posteriorly to the left, away from the surgeon and the back row is completed. Once the anterior row is completed, the graft is cannulated (if direct aortic cannulation has been used), deaired and clamped and cardiopulmonary bypass is re-instituted. The proximal anastomosis and additional procedures are then performed during the re-warming phase of the operation. The graft is now oriented in such a way that a simple end-to-end anastomosis can easily be accomplished proximally (Fig. 1). The final result is a conduit that sits in proper orientation without tension or kinking.
3. Comment
A simple bevel with orientation opposite to that which is typically described allows for immediate proper positioning of the reconstructed aorta. Kinks are avoided along the graft and both proximal and distal anastomoses are tension-free and the reconstruction is aesthetically appealing. The simplicity of the technique saves time. Circulatory arrest times are generally in the range of 10–20 min. This particular orientation gives the graft a straight course that puts it in immediate contact with the pulmonary artery.
The reconstruction presumes that the graft has been trimmed appropriately. A graft that is cut too long will almost inevitably kink upon completion of the anastomoses, regardless of bevel technique. However, a graft that is cut to an appropriate length will still have a tendency to kink if the distal end is not beveled correctly. Both factors are very important considerations, when reconstruction of the ascending aorta and arch is performed.
Other authors have described similar distal beveling techniques with minor variations [1]. We have used this method routinely in patients requiring ascending aortic and arch reconstructions for type A dissections and aneurysmal disease. The naturally positioned tension-free anastomosis facilitates hemostasis and avoids the need to plicate the inner curvature of the graft to treat kinking [4]. The senior author (GP) has used the technique routinely for more than 10 years and has not recognized any adverse events related to trimming of the graft in this manner.
References
Ravichandran PS, Floten HS, Swanson JS, Gately HL, Hovaguimian H, Furnary AP, Starr A. Reversed bevel technique for anastomosis at the aortic arch. Ann Thorac Surg 1996; 61:245–246.
Shiiya N, Yasuda K. A new method for graft tailoring in hemiarch replacement. Ann Thorac Surg 2004; 78:1105–1106.
Misfeld M, Scharfschwerdt M, Sievers HH. A novel form-stable, anatomically curved vascular prosthesis for replacement of the thoracic aorta. Ann Thorac Surg 2004; 78:1060–1063.
Svensson LG. Invited Commentary. Ann Thorac Surg 2004; 78:1063.(Arash Salemi and Gosta B.)
Abstract
We describe a simple method for ascending aorta and heimarch/arch reconstruction that reduces tension, avoids graft kinking, and provides optimal orientation for the proximal anastomosis.
Key Words: Anastomosis; Aortic surgery; Aortic arch
1. Introduction
The normal ascending aorta and aortic arch are smoothly curved with an inner contour that is shorter than the outer. After resection and replacement with a vascular prosthesis, graft kinking is a common issue. The result is often a suboptimal reconstruction.
The distal graft is beveled for anastomosis below the arch vessels. As typically described, the graft bevel is fashioned to accommodate the curve of the arch with the tongue of the graft pointed towards the patient's left side. The subsequent anastomosis proximally, either to the aorta or to an ascending graft, is then constructed in a manner that must take into consideration two opposing angles. Further graft beveling is often required. The consequence is frequently kinking, tension, or anterior displacement of the anastomosis. This latter circumstance would be particularly concerning in the event of re-sternotomy.
While appropriate graft length is critical in preventing such outcomes, it must be associated with a carefully fashioned distal anastomosis to ensure a good result. Several authors have proposed alternate beveling techniques to help avoid the aforementioned complications [1,2]. A curved vascular prosthesis has also been manufactured to address this issue [3].
We describe a simple graft trimming technique that affords appropriate orientation and, when associated with precise graft length, helps to avoid the potential hemodynamic consequences of kinking.
2. Technique
We utilize the right axillary artery and the ascending aorta as our preferred cannulation sites. Retrograde cerebral perfusion is used during the circulatory arrest period. After circulatory arrest is instituted, the aortic arch is resected back as required. Most often a hemiarch resection is performed, leaving the innominate artery and the left common carotid artery in continuity with the distal aorta. Selection of the vascular prosthesis is determined by the size of the proximal aorta. Distally, the graft is trimmed to accommodate the circumference of the distal opening and to allow the graft to have a straight course. This is guided by the appearance of the open distal aorta. The graft is trimmed to allow a straight rather than curved connection between the two ends of the aorta. Generally, the cut angle is between 30 and 60 degrees. The distal anastomosis is performed with the tongue of the graft directed towards the patient's right shoulder. Suturing is then begun posteriorly to the left, away from the surgeon and the back row is completed. Once the anterior row is completed, the graft is cannulated (if direct aortic cannulation has been used), deaired and clamped and cardiopulmonary bypass is re-instituted. The proximal anastomosis and additional procedures are then performed during the re-warming phase of the operation. The graft is now oriented in such a way that a simple end-to-end anastomosis can easily be accomplished proximally (Fig. 1). The final result is a conduit that sits in proper orientation without tension or kinking.
3. Comment
A simple bevel with orientation opposite to that which is typically described allows for immediate proper positioning of the reconstructed aorta. Kinks are avoided along the graft and both proximal and distal anastomoses are tension-free and the reconstruction is aesthetically appealing. The simplicity of the technique saves time. Circulatory arrest times are generally in the range of 10–20 min. This particular orientation gives the graft a straight course that puts it in immediate contact with the pulmonary artery.
The reconstruction presumes that the graft has been trimmed appropriately. A graft that is cut too long will almost inevitably kink upon completion of the anastomoses, regardless of bevel technique. However, a graft that is cut to an appropriate length will still have a tendency to kink if the distal end is not beveled correctly. Both factors are very important considerations, when reconstruction of the ascending aorta and arch is performed.
Other authors have described similar distal beveling techniques with minor variations [1]. We have used this method routinely in patients requiring ascending aortic and arch reconstructions for type A dissections and aneurysmal disease. The naturally positioned tension-free anastomosis facilitates hemostasis and avoids the need to plicate the inner curvature of the graft to treat kinking [4]. The senior author (GP) has used the technique routinely for more than 10 years and has not recognized any adverse events related to trimming of the graft in this manner.
References
Ravichandran PS, Floten HS, Swanson JS, Gately HL, Hovaguimian H, Furnary AP, Starr A. Reversed bevel technique for anastomosis at the aortic arch. Ann Thorac Surg 1996; 61:245–246.
Shiiya N, Yasuda K. A new method for graft tailoring in hemiarch replacement. Ann Thorac Surg 2004; 78:1105–1106.
Misfeld M, Scharfschwerdt M, Sievers HH. A novel form-stable, anatomically curved vascular prosthesis for replacement of the thoracic aorta. Ann Thorac Surg 2004; 78:1060–1063.
Svensson LG. Invited Commentary. Ann Thorac Surg 2004; 78:1063.(Arash Salemi and Gosta B.)