Volume 140, Issue 2 , Pages 488-489, August 2010
Benefit of using total arch replacement combined with stented elephant trunk implantation during arch reconstruction
Article Outline
To the Editor:
We read with great interest the recent article by Xydas and colleagues.1 In this study, they introduced a novel technique using left carotid–subclavian bypass (CSB) before arch replacement with staged thoracic stent grafting to achieve hybrid arch reconstruction. Compared with the conventional method, the major advantage of this technique is using prepared CSB to anastomose the left carotid artery to the graft before cardiopulmonary bypass (CPB). Only 2 anastomoses (anastomoses of the distal graft to the aorta and the graft to the innominate artery) must be done during hypothermic circulatory arrest (HCA), decreasing selective antegrade cerebral perfusion (SACP), CPB and aortic crossclamp times, and limiting HCA.
Currently, HCA with SACP is widely used as routine means to protect the central nervous system during aortic arch replacement; however, to some degree, the safe time of HCA with SACP is limited. Therefore, the best way to protect the brain and spinal cord is to shorten the period of HCA as much as possible. Even though the technique of Xydas and associates1 mentioned in this article could reduce the HCA time by using CSB to complete the anastomosis of the left carotid artery to the graft off CPB, we still think a few questions and limitations need to be considered when using this method. First, the premise of using CSB depends on the pathologic changes of the arch without spreading to the left subclavian artery. Second, might the shunt of CSB lead to cerebral malperfusion during this short term? Third, compared with the technique we used (total arch replacement combined with stented elephant trunk implantation, which we called the “Sun's procedure” 2, 3, 4 Xydas' method still requires staged thoracic stent grafting to achieve hybrid arch reconstruction.
In our opinion, the Sun's procedure for arch reconstruction is more efficient, simple, and safe. The Sun procedure has been advocated and developed by our research group since 2003.5, 6 Herein, we have summarized the Sun's surgical procedure and made a comparison with the CBS procedure.
A stent graft (MicroPort Medical Company Limited, Shanghai, China) (Figure 1) and 4-branched prosthetic graft (Meadox Hemashield Platinum 4 Branch Graft; Boston Scientific Inc, Boston, Mass) were used in total arch replacement combined with stented elephant trunk implantation. Cannulation of the right axillary artery was used for CPB and SCP. The arterial line was bifurcated for the right axillary artery and for lower body perfusion via 1 branch of a 4-branched prosthetic graft. During cooling, the proximal ascending aorta was opened longitudinally, and aortic root procedures could be done if necessary. HCA was established when the target temperature was reached. SACP was initialed through the right axillary artery. The ascending aorta and transverse arch were opened. The stented elephant trunk was then inserted into the true lumen of the descending thoracic aorta in a compressed state. The proximal edge of the residual aorta was trimmed to match the proximal end of the stent graft. The anastomosis between the 4-branched prosthetic graft and the distal aorta containing the intraluminal stented graft was carried out using the “open” aortic technique. Once the anastomosis was completed, lower body perfusion was started via the limb of the 4-branched prosthetic graft. Then the left common carotid, innominate, and left subclavian arteries were anastomosed to the respective limbs of the 4-branched prosthetic graft in an end-to-end style in turn.
Figure 1
Stented graft. A, Catheter sheath containing the stented graft in a bound and compressed state. B, Stent graft springs open and expands completely.
In conclusion, the benefits of the Sun's procedure (1) result in less late dilatation of the dissected descending aorta, (2) prolong the reoperation interval or reduce the number of late thoracoabdominal aortic replacements except in a patent false lumen around the stented elephant trunk, and (3) facilitate late thoracoabdominal aortic replacement. Other than that, compared with the CSB procedure, only 1 anastomosis needs to be finished under HCA with SACP, which could shorten SACP time during HCA, possibly decreasing cerebral injury during HCA and also avoiding radiology exposure to the patients with staged thoracic stent grafting to achieve hybrid arch reconstruction.
References
- Use of carotid–subclavian arterial bypass and thoracic endovascular aortic repair to minimize cerebral ischemia in total aortic arch reconstruction. J Thorac Cardiovasc Surg. 2010;139:717–722
- Surgery for Marfan patients with acute type a dissection using a stented elephant trunk procedure. Ann Thorac Surg. 2008;86:1821–1825
- Surgery for acute type A dissection using total arch replacement combined with stented elephant trunk implantation: experience with 107 patients. J Thorac Cardiovasc Surg. 2009;138:1358–1362
- Surgery for acute type A dissection with the tear in the descending aorta using a stented elephant trunk procedure. Ann Thorac Surg. 2009;87:1177–1180
- Should the “elephant trunk” be skeletonized? Total arch replacement combined with stented elephant trunk implantation for Stanford type A aortic dissection. J Thorac Cardiovasc Surg. 2006;131:107–113
- The application of a modified technique of SCP under DHCA during total aortic arch replacement combined with stented elephant trunk implantation. Perfusion. 2006;21:255–258
PII: S0022-5223(10)00430-7
doi:10.1016/j.jtcvs.2010.02.053
© 2010 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.
Refers to article:
- Use of carotid–subclavian arterial bypass and thoracic endovascular aortic repair to minimize cerebral ischemia in total aortic arch reconstruction , 18 January 2010
Volume 140, Issue 2 , Pages 488-489, August 2010
