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J Thorac Cardiovasc Surg 1999;118:208
© 1999 Mosby, Inc.

LETTERS TO THE EDITOR

Arch-first technique through left antero-axillary thoracotomy or bilateral anterior thoracotomy

Shiro Sasaguri, MD, Tomonobu Fukuda, MD

Department of Thoracic and Cardiovascular Surgery
Juntendo University
2-1-1 Hongo
Bunkyo-ku
Tokyo, 113, Japan

To the Editor:

We read with great interest the article by Rokkas and Kouchoukos titled "Single-Stage Extensive Replacement of the Thoracic Aorta: The Arch-First Technique." They report that a bilateral thoracotomy enabled an arch-first reconstruction preceding proximal or distal aortic anastomosis, as well as retrograde cerebral perfusion through the superior vena cava (SVC) for cerebral protection during deep hypothermic circulatory arrest in an extensive replacement of the thoracic aorta.Go 1 We totally agree with their strategy for reconstruction of the aortic arch.

However, we do not believe that these techniques are original with them. We have already advocated the use of a left antero-axillary thoracotomy, which is less invasive than a bilateral thoracotomy, as an alternative approach for aortic arch reconstruction.Go Go 2,3 This type of thoracotomy combines the advantages of each approach, while filling a gap between a median sternotomy and posterolateral thoracotomy, by providing a wide view of the aortic arch from the ascending aorta to the mid-descending aorta and allowing access to the SVC for a retrograde cerebral perfusion during deep hypothermic circulatory arrest. Furthermore, the possibility for the precedence of reconstruction of arch vessels through the left antero-axillary thoracotomy, and then the reperfusion to the arch vessels through a side branch of the graft before anastomosing the graft to the ascending aorta or descending aorta (which may shorten the period of cerebral ischemia), has already been explained in our article.

A bilateral thoracotomy that requires a transverse sternotomy, ligation of both internal thoracic arteries, and entrance to both sides of the pleural cavities seems to be more invasive than a left antero-axillary thoracotomy. The pericardial stitch, which is placed at the corner of the pericardial reflection on the SVC, can raise the SVC and pull out the ascending aorta toward the operative field, thus facilitating aortic and SVC cannulations even through a left antero-axillary thoracotomy.Go 4

Thus the arch-first technique through a bilateral thoracotomy seems to achieve excellent results albeit with a far more extensive incision.

12/8/98435

References

  1. Rokkas CK, Kouchoukos NT. Single-stage extensive replacement of the thoracic aorta: the arch-first technique. J Thorac Cardiovasc Surg 1999;117:99-105.[Abstract/Free Full Text]
  2. Sasaguri S, Yamamoto S, Fukuda T, Hosoda Y. Anteroaxillary thoracotomy facilitates the use of retrograde cerebral perfusion in distal aortic arch reconstruction. Ann Thorac Surg 1996;62:1861-2.[Abstract/Free Full Text]
  3. Sasaguri S, Yamamoto S, Fukuda T, Hosoda Y. Retrograde cerebral perfusion through antero-axillary thoracotomy in the aortic arch surgery. Eur J Cardiothorac Surg 1997;11:657-60.[Abstract]
  4. Sasaguri S, Fukuda T, Hosoda Y. Pericardial lift facilitates central cannulation in antero-axillary thoracotomy. Ann Thorac Surg 1999;67:597.[Free Full Text]




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