Total arch replacement using a stepwise distal anastomosis for arch aneurysms with distal extension☆

Abstract

A total of 120 patients having arch to distal arch aneurysm with downstream extension underwent total arch replacement, with individual arch-vessel reconstruction through median sternotomy using a novel "stepwise" distal aortic anastomosis. Cardiopulmonary bypass was established by cannulating the right axillary artery and the ascending aorta or femoral artery. Hypothermia was at 22-28 degrees C. Through the aneurysm, the descending aorta was divided. Distal anastomosis using the stepwise technique was performed; a tube graft of length 7-12 cm was inserted into the descending aorta and anastomosed by running suture. The distal end of the inserted graft was extracted, and a further four-branched arch graft was joined to it. Selective cerebral perfusion was used for cerebral safety during arch repair. There were three hospital deaths (2.5%). Two patients (1.7%) developed permanent neurological dysfunction and three patients (2.5%) suffered transient cerebral deficits. Three patients (2.5%) required reentry for postoperative bleeding although in none of them bleeding was from the distal anastomosis site with the stepwise technique. Stepwise anastomosis is a useful and secure alternative for distal anastomosis in total arch replacement for arch to distal arch aneurysms with distal extension.

Hybrid Repair Combined with Open Surgery and Endografting for Lesions in Right Aortic Arch: Report of Three Cases

“…3,4) The most frequent RAA has no retroesophageal segment or mirror image branching (77%). RAA with a retroesophageal segment is rare (4%).…”

“…2) Our basic strategy for treatment of an aneurysm or dissection of the arch is total arch replacement. 3) However, to deal with the risks or problems associated with patients with RAA, we chose hybrid repair including the use of TEVAR for the three cases.…”

Inverted graft insertion technique for apicoaortic bypass

“…Ogino and colleagues have reported that they routinely use the graft-inversion technique called 'stepwise technique' for open distal aortic anastomosis under circulatory arrest [3]. They have reported that this technique is easy and useful to achieve favourable haemostasis.…”

The use of a self-expanding ring to facilitate distal anastomosis in total arch replacement

“…Several techniques for performing this procedure have previously been documented. [4][5][6] Performing a precise distal anastomosis is critical in total arch replacement surgery because of the difficulty in controlling the bleeding from this site and the risk of a potentially fatal infection if there is an injury to the nearby esophagus or lung. While the malleable ring is still useful in some cases, we were challenged to develop an alternative because it was difficult to insert and make adjustments in the size.…”