Techniqueof “open’’ distal anastomosis for ascending
`and transverse arch resection
`
`Denton A.
`
`Cooley, M.D., and James J. Livesay, M.D.
`
`To ensure continuous cerebral
`resection and
`graft
`perfusion during
`in most
`with lesions that involve the
`and
`replacement
`ascending
`patients
`ofthe distal oc-
`aortic arch, surgical repair requires placement
`proximal
`of the innomimate artery. Of-
`to the
`clamp
`cluding
`just proximal
`origin
`pathologic process extends into the arch or
`ten, however, the
`beyond
`and may
`of the innominate, left carotid, and left sub-
`the
`involve
`origin
`does not ensure the restoration of normal
`clavian arteries. This
`practice
`to arch vessels and may encourage cerebral embolization from
`perfusion
`atherosclerotic debris; for acute
`dissecting aneurysms, it may leadto fur-
`of the
`ther
`from friable dissected
`and
`layers
`hemorrhage
`disruption
`aorta. A solution to these technical
`problems may be
`provided by using
`an
`arrest and
`distal anastomosis
`“open”
`by performingthe
`by
`
`circulatory
`technique.
`
`Method
`
`After the median sternotomy
`made, the extent of the aortic lesion
`is
`heparin administered, cannulation of a common femoral
`and
`appraised,
`Selection of the site for the venous outflow cannula
`artery is
`performed.
`or cannulae
`The choices include
`depends upon the anatomic
`findings.
`atrium, the outflow tract of the
`the
`right ventricle, and/or the infe-
`right
`rior vena Cava via a common femoralvein.
`
`From the Division of
`Texas Heart Institute of St. Luke’s
`Surgery,
`Texas Children’s Hospitals, Houston, Texas
`
`Episcopal
`
`and
`
`Denton A.
`Address for
`reprints:
`20345, Houston, Texas 77025
`
`Cooley, M.D., Texas Heart Institute, P.O. Box
`
`Cardiovascular Diseases,Bulletin of the Texas HeartInstitute
`Volume 8
`Number 3
`
`September 1981
`
`421
`
`MEDTRONIC 1110
`
`MEDTRONIC 1110
`
`
`and transverse arch resection
`
`Denton A.
`
`Cooley, M.D., and James J. Livesay, M.D.
`
`To ensure continuous cerebral
`resection and
`graft
`perfusion during
`in most
`with lesions that involve the
`and
`replacement
`ascending
`patients
`ofthe distal oc-
`aortic arch, surgical repair requires placement
`proximal
`of the innomimate artery. Of-
`to the
`clamp
`cluding
`just proximal
`origin
`pathologic process extends into the arch or
`ten, however, the
`beyond
`and may
`of the innominate, left carotid, and left sub-
`the
`involve
`origin
`does not ensure the restoration of normal
`clavian arteries. This
`practice
`to arch vessels and may encourage cerebral embolization from
`perfusion
`atherosclerotic debris; for acute
`dissecting aneurysms, it may leadto fur-
`of the
`ther
`from friable dissected
`and
`layers
`hemorrhage
`disruption
`aorta. A solution to these technical
`problems may be
`provided by using
`an
`arrest and
`distal anastomosis
`“open”
`by performingthe
`by
`
`circulatory
`technique.
`
`Method
`
`After the median sternotomy
`made, the extent of the aortic lesion
`is
`heparin administered, cannulation of a common femoral
`and
`appraised,
`Selection of the site for the venous outflow cannula
`artery is
`performed.
`or cannulae
`The choices include
`depends upon the anatomic
`findings.
`atrium, the outflow tract of the
`the
`right ventricle, and/or the infe-
`right
`rior vena Cava via a common femoralvein.
`
`From the Division of
`Texas Heart Institute of St. Luke’s
`Surgery,
`Texas Children’s Hospitals, Houston, Texas
`
`Episcopal
`
`and
`
`Denton A.
`Address for
`reprints:
`20345, Houston, Texas 77025
`
`Cooley, M.D., Texas Heart Institute, P.O. Box
`
`Cardiovascular Diseases,Bulletin of the Texas HeartInstitute
`Volume 8
`Number 3
`
`September 1981
`
`421
`
`MEDTRONIC 1110
`
`MEDTRONIC 1110
`
`
`
` Lh
`
`7
`Z
`Soto
`eeSTILL
`KLM
`
`Fig. 1 During hypothermiccirculatory arrest at 23 to 24°C and with the arch vessels clamped,
`the aneurysm is opened widely to exposethe distal transverse arch. In theillustration, a dis-
`secting aneurysm is depicted with the true and false lumens.
`
`Cooling
`
`the heat
`is started, and, using
`Cardiopulmonary bypass
`exchanger,
`patient’s body temperature is lowered to 24°C. During
`the
`this interval,
`appropriate time, the vessels are
`the arch vessels are mobilized. At the
`cross-clamped (Fig. 1). The arterial return
`discontinued and
`pump is
`the venous outflow is occluded.
`
`Excision and Repair
`
`aorta and a suction
`An incision is madein the
`is inserted
`tip
`ascending
`to withdraw blood from the aorta and left ventricle. A left atrial sump
`may
`be used to ensure a bloodless field around the aortic root. To
`also
`accommodatethe
`aspirated blood, additional reservoir space is needed
`in the extracorporealcircuit.
`aorta is
`condition of
`The
`and the
`ascending
`pathologic
`opened widely
`the interior of the transverse arch and
`of the arch vessels is ap-
`origin
`dissecting aneurysms, the definition of the true and
`praised (Fig. 1). For
`422
`
`MEDTRONIC 1010
`
`MEDTRONIC 1010
`
`
`
`
` RESSSSS
`
`Fig. 2 The “open” anastomosis facilitates proper managementof the double lumen aorta. A
`continuous polypropylene suture closes the false lumen and directs the entire aortic flow into
`the true lumen.
`
`the dissected false lumen must be established.
`the
`Usually
`the lesion whetherit is of a
`arch tributaries is
`spared by
`atherosclerotic type.
`
`of the
`or
`
`origin
`dissecting
`
`Graft
`
`A low
`size
`porosity Veri-soft Woven Dacron Graft* of
`appropriate
`We use
`should
`have beenselected and
`already
`prepared by preclotting.
`it in a steam
`to soak the
`fresh
`and then
`autologous plasma
`graft
`place
`autoclave for five minutes. This method ensures that
`bleeding through
`the interstices of the fabric will be minimal.
`
`*Meadox Medicals, Inc., Oakland, New
`
`Jersey, U.S.A.
`
`423
`
`MEDTRONIC 1010
`
`MEDTRONIC 1010
`
`
`
`5
`<I
`STs
`5
`|
`\
`|
`-
`.
`.
`A=
`Life Fo
`n,
`NI, wu SS
`); li
`~
`aoe mR F
`I IN y
`LJ
`7
`a HIS
`>
`‘
`y
`=
`Uy )
`\ WY
`SK 7
`\\<
`Na
`| \\
`vx a
`))
`Ny
`|
`\ \'
`(
`La
`=
`NX Sap
`ro S i
`i, OD
`oN RY
`Sy K)
`™~
`p
`fy
`K\
`rc,
`mo
`K
`fy:
`fo
`
`.
`
`/
`
`7
`
`’
`
`]
`
`)
`
`6
`
`.
`
`A
`
`,
`
`f
`
`J
`oat
`:
`
`Mo
`
`i Fig. 3 The distal anastomosis is completed and arterial return graduallyfills the aorta and
`
`proximal segmentof the fabric graft to eliminate entrappedair.
`
`Anastomosis
`
`su-
`with a 48-inch
`The distal anastomosis is
`performed
`polypropylene
`ture of either 3-0 or 2-0 diameter, depending
`somewhatuponthe firm-
`nessofthe tissues. For
`sutureline incor-
`dissecting aneurysms, the single
`porates both the inner and outer
`of the aortic wall
`(Fig. 2).
`layers
`Particular attention is madeto ensurethatthe true lumenofthe aortais
`in
`with the lumen of the innominate and carotid arteries and
`continuity
`or
`that the false lumen is obliterated at the suture line.
`Invaginating
`inside the true lumenis advisable. The continuous
`the
`graft
`telescoping
`suture
`the distal anastomosis
`(Fig. 3).
`completes
`aorta and arch, when the blood
`Toeliminate air from the
`descending
`level has reached the
`of the
`graft, cardiopulmonary bypass
`midportion
`acrossthe
`and a clamp
`as the arch vessels
`is started
`slowly,
`is placed
`graft
`are
`is
`unclamped(Fig. 4). The
`of
`circulatory interruption
`period
`
`usually
`
`424
`
`MEDTRONIC 1010
`
`MEDTRONIC 1010
`
`
`
`
`
`Gy
`nN /
`We
`Ne Za \)
`
`
`
`ZZ
`Ey
`
`
`
`OF
`
`YN
`
`tag,
`
`
`V1"
`
`
`ni
`
`Fig. 4 A clampis placed across the graft and the clamp is removed from the arch vessels.
`The proximal anastomosis is then performed while the patient is being rewarmed.
`
`should be safe
`
`less than 10 minutes in our
`but
`longer periods
`patients,
`in the central nervous
`without
`anoxic
`system.
`changes
`producing
`continues as the
`If
`anastomosis is
`performed.
`Rewarming
`proximal
`or annuloaortic ectasia, the valve
`the
`has aortic valve
`patient
`pathology
`or the entire aortic root may be
`with a
`valve-contain-
`replaced
`composite
`is continued until the patient’s
`conduit.
`ing
`Cardiopulmonary bypass
`temperaturehasrisen to 36 or 37°C. After the venous cannulaeare re-
`the
`moved, the
`is counteracted
`Coumadin.
`Bleeding through
`heparin
`by
`the
`is minimal. When
`hemostasis has been
`graft
`general
`accomplished,
`is closed in the usual manner.
`sternotomy
`
`incision
`
`Comment
`
`This
`out
`
`of open anastomosis has been used in 18
`patients
`technique
`occasional transient
`and with
`only
`mortality
`neurologic complica-
`425
`
`with-
`
`MEDTRONIC 1010
`
`MEDTRONIC 1010
`
`
`
`tions. Not
`lesions of the aorta,
`is the method useful for
`dissecting
`only
`butit can also be
`with atherosclerosis in
`in
`applied successfully
`patients
`to
`aorta
`of the
`whom
`multiple
`cross-clamping
`ascending
`predisposes
`man
`cerebral emboli from atherosclerotic debris. In one
`24-year-old
`of the en-
`whohad
`aortic stenosis and diffuse
`narrowing
`supravalvular
`tire transverse arch and branches (caused by hyperplasia
`of the intimal
`that was
`and medial
`aortic
`a
`specimen
`endarterectomy produced
`layers),
`a
`“cast” of the aortic arch.
`complete
`In a
`we described a more
`method
`previous communication,
`complex
`in which we used temporary perfusion
`of the
`of aortic arch
`replacement
`innominate and left commoncarotid arteries.” We nowbelieve that arch
`safe with the use of moderate
`and
`is
`simpler
`relatively
`temporary circulatory arrest, and internal
`
`hy-
`graft replace-
`
`replacement
`pothermia,
`ment.
`
`References
`
`1.
`
`Bossart MI: A method of
`Cooley DA, Romagnoli A, Milam
`JD,
`preparing
`woven dacron
`to
`Cardiovasc Dis,
`prevent interstitial hemorrhage.
`grafts
`Bull Texas Heart Inst 8:48-52, 1981
`treatment of aneu-
`2. Cooley DA, Ott DA, Frazier OH, Walker WE:
`Surgical
`rysms of the transverse aortic arch:
`with
`tech-
`Experience
`in 25
`Ann Thorac
`Surg (in press)
`niques
`patients.
`
`hypothermic
`
`426
`
`MEDTRONIC 1010
`
`MEDTRONIC 1010
`
`
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