Mini-access open arch repair

Abstract

The use of minimally invasive approaches is scarce in open aortic arch repair because of its perceived high operative risk and technical difficulty. Methods:This study enrolled 59 consecutive patients (aged 58.2±13.2 years) undergoing elective arch replacement either through upper hemi-sternotomy (n=58) or mini-thoracotomy (n=1) between 2015 and 2020. Of these, 44 underwent hemiarch replacement and 15 underwent total arch replacement. Moderate hypothermic circulatory arrest was used for all patients while antegrade cerebral perfusion was selectively used for total arch repair. For more efficient distal aortic anastomosis in limited spaces, inverted graft anastomosis was utilized whenever possible. Results:Hemi-sternotomy involved upper sternal separation down to the second, third, and fourth intercostal spaces in 1 (1.7%), 30 (50.8%), and 27 (45.8%) patients, respectively. Concomitant cardiac procedures included root replacement in 19 patients (32.2%) and aortic valve replacement in 21 patients (35.6%). Circulatory arrest, cardiac ischemic, cardiopulmonary bypass, and total procedural times were 8.9±3.4, 91.1±31.1, 114.6±46.2, and 250.3±79.5 min, respectively for total arch repair, and 25.0±12.1, 72.3±16.6, 106.0±16.9, and 249.1±41.7 min, respectively for hemiarch repair. Conversion to full-sternotomy was required in 1 patient (1.7%) due to bleeding. There was one case of mortality (1.7%) attributable to low-cardiac output syndrome following hemiarch repair concomitantly with Bentall procedure. Major complications included requirement for mechanical support in 1 (1.7%), temporary neurologic deficit in 1(1.7%), newly initiated dialysis in 3 (5.1%), and re-exploration due to bleeding in 2 (3.4%). Conclusions:Mini-access open arch repair is technically feasible and achieved excellent early outcomes.

Tailored surgical strategies for mini-access open total arch repair

“…First, the mini-access group actively used the inverted graft technique ( P < .001) for anastomosis strategy, resulting in a relatively low use of 4-branch graft ( P = .019). As previously reported by our institution, 15 the inverted graft technique is an efficient method for performing arch distal anastomosis in a limited field of view, with excellent hemostatic effects. This efficiency can be maximized when used together with a trifurcated graft to proceed with surgery using the arch-first strategy.…”

“… 14 To facilitate effective distal anastomosis in a limited surgical field, an inverted graft technique was utilized whenever feasible, as previously suggested. 15 This entailed rolling the graft itself in an inside-out fashion, which allows excellent exposure of the distal anastomosis site without hindrance by the graft body. The distal anastomosis was performed using a double layer 3–0 polypropylene suture on the proximal descending aorta.…”

Comparative Analysis of Long-Term Outcomes in Valve-Sparing Aortic Root Reimplantation: Full Sternotomy versus Mini-Sternotomy Approach

“…In the previous series, one patient underwent hemi-arch replacement via V-shaped mini-sternotomy. It has to be noted that such partial upper hemisternotomy has proved safe not only for aortic root surgery but also complex aortic arch procedures [24]. While acknowledging the importance of individual surgeon experience and patient factors, the study contributes to the growing body of evidence supporting the use of the minimally invasive technique in a broader range of aortic surgeries.…”

Mini-access ascending aorto-bifemoral bypass surgery for the treatment of aortic steno-occlusive disease

“…The study results should be interpreted with caution because they are derived from a high-volume, tertiary referral cardiovascular surgical center that has been highly specialized in minimally invasive surgery for not only valvular diseases but also aortic lesions. 13 , 15 , 16 Therefore, the results may not be generalizable to other settings, and there should be steep learning curves to achieve sufficient levels to handle meticulous procedures within limited exposure. In addition, we believe the number of surgical cases shared in the present article is not small given the rarity of illness; however, the experiences should be verified by larger data.…”