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J Thorac Cardiovasc Surg 2000;120:672-678
© 2000 The American Association for Thoracic Surgery
Surgery for Acquired Cardiovascular Disease |
From the First Department of Surgery, Hiroshima University School of Medicine, Hiroshima, Japan.
Address for reprints: Kazumasa Orihashi, MD, First Department of Surgery, Hiroshima University School of Medicine, Kasumi 1-2-3, Minami-ku, Hiroshima 734-8551, Japan (E-mail: ka-ori{at}mcai.med.hiroshima-u.ac.jp).
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Abstract |
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Introduction |
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1,2 It covers aneurysms adjacent to the left subclavian artery (SCA) with a short proximal neck. When graft deployment adjacent to the left SCA causes malperfusion, transposition of the SCA and common carotid artery is added. 2 Surgical endovascular stent grafting through a midsternal approach is indicated in cases of aneurysm or dissection adjacent to or involving the left SCA(Fig 1), 3,4 especially when associated surgery, such as coronary artery bypass grafting (CABG), is necessary. Because lung compression through the left thoracotomy is spared, lung damage is minimal. Compared with the conventional aortic replacement through the midsternal approach, distal anastomosis in the deep and poor visual field is omitted, reducing time and bleeding at the distal anastomosis. Associated surgery is done while the patient is cooled. Left-to-right SCA bypass is added as needed.
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1,2 cannot detect intimal damage caused by catheter manipulation. These problems can be solved with an appropriate imaging modality. We have introduced transesophageal echocardiography (TEE) to visualize endovascular devices, as well as the aorta. In this article our initial experience is reported, with discussion on the merits and problems of using TEE.
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Methods |
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4 The graft size was determined on the basis of the computed tomography (CT) and TEE data, and a graft of 0 to 4 mm larger in size was used. Associated surgical procedures were completed while the patient was cooled to a rectal temperature of 25°C. The stent-graft was loaded in a 30F catheter before aortotomy. Under circulatory arrest with selective cerebral perfusion established, the anterior wall of the aorta was incised by half of its circumference at just distal to the SCA(Fig 1
, A). The aorta was transected in patients with aortic dissection or total arch replacement. The catheter was inserted into the descending aorta, and the graft was pushed out of the catheter(Fig 1, B). After the distal stented portion expanded, excessive unstented graft out of the aortotomy was cut off. The proximal end was sutured to the aortic wall; the posterior half was sutured with the inclusion method, and the anterior half was sutured to the incised edge of the aorta. In cases of aortic dissection, the transected aortic wall was reinforced between the internal graft and an external felt strip. Cardiopulmonary bypass was resumed after the aortotomy was closed(Fig 1, C).
Use of TEE
A 5-MHz biplane TEE (EUB-555, Hitachi Co, Tokyo, Japan) was instituted and used for intraoperative routine monitoring, as well as for this procedure. Transverse and longitudinal views were simultaneously displayed side by side(Fig 2). The aortic intima was examined for fragile plaques, and the internal diameter at the anticipated attachment portion was measured before circulatory arrest(Fig 1, A). When the cross section of aorta was not round, as in cases of dissection, the circumference was measured, and the diameter was calculated. In visualizing the aorta exactly in the short axis, the TEE probe was manipulated so that the corresponding long-axis view was depicted as coursing horizontally on the display.
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5 with the stent-graft packed inside(Fig 2). When the catheter tip was directed to the aortic wall or the intimal flap and could cause damage, the catheter was reshaped and inserted again. The distal end of the graft was located by measuring the distance from the diaphragm. After the diaphragm was visualized at the center in a longitudinal scan, the probe was withdrawn until the graft tip was visualized at the center. The difference of depths of the TEE probe between these 2 levels was defined as the distance from the diaphragm(Fig 1, B). When not clearly visualized, the celiac trunk was visualized as reported before 6 and was used as another reference. The length of the attachment portion was defined as the distance between the distal end of the aneurysm or entry site and the graft tip. We tried to leave an attachment portion of 4 cm or longer and maintain the distance from the diaphragm at 9 cm or longer (approximately 3 vertebrae). Attachment of the graft to the aortic wall was assessed as adequate when there was no gap (B mode) without a flow signal (color Doppler mode) between them. When the distal end of the graft was curved inward, it was reformed with balloon inflation by using a Foley balloon catheter located and inflated under TEE guidance to avoid an intimal injury(Fig 3). The result was immediately assessed, and dilatation was added if necessary.
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Postoperative assessments
The position of the stent was examined by chest radiography in the intensive care unit. The following assessments were made with CT, angiography, or both: (1) adequacy of graft size; (2) endoleak; (3) leak at the proximal anastomosis; (4) stenosis at the stentless portion; and (5) thrombosis exclusion.
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Results |
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The aortic diameter varied from 20 to 30 mm, and the graft size was 22 to 32 mm(Table I). Intimal injury during catheter insertion or balloon inflation was not seen in any patient. The distal end of the graft was at 9 cm or farther from the diaphragm, except in patient 11, in whom a thick atheromatous plaque was found at the proximal descending aorta. The graft was intentionally implanted more distally than usual to cover this portion with the graft so that the graft might not dig into the atheromatous plaque. However, paraplegia developed postoperatively in this patient. In early patients the position of the catheter tip was not determined before releasing the graft. In patient 4 the graft tip was found at only 5 cm from the celiac trunk. The graft was pulled by 8 cm, leaving the attachment portion longer than 5 cm. In patient 11 the graft was 7 cm from the diaphragm for the above-mentioned reason. The surgeon was concerned about possible obstruction of the artery of Adamkiewicz and tried to withdraw the graft. However, the graft did not move, probably because the graft size was 3 mm larger than the aortic diameter. In subsequent patients the catheter tip was located before graft deployment. The postoperative chest x-ray film depicted the stent within the proximal half of the descending thoracic aorta, except in patients 11 and 14. In the latter a tortuous aorta was responsible while the graft was 10 cm away from the hiatus.
The attachment portion was longer than 5 cm, except in 3 patients. In patient 6 a gap around the graft was apparent(Fig 4, A; endoleak). In patients 3 and 14 the attachment portion was short. Minor leakage at the proximal suture, stenosis at the stentless portion, and flow in the residual lumen were found in 3, 3, and 4 (apparent in 2) patients, respectively.
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, B). Thromboexclusion was successful in 13 patients and unsuccessful in 1 patient. This result was compatible with TEE assessment, with both a sensitivity and specificity of 100%. Proximal leakage or kinking of the graft was detected in 1 of 3 patients with positive TEE findings. Specificity was 100% for both. Among 13 patients with successful thromboexclusion, 5 patients showed complete regression of aneurysm dissection during the follow-up period of 6 to 31 months. Aneurysm disappeared in patients 1, 2, and 10 after 16, 18, and 2 months, respectively, whereas thrombosed false lumen disappeared in patients 4 and 5 after 4 and 8 months, respectively(Fig 5). The size of the aneurysm is regressing in all of the remaining 8 patients.
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Comment |
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The first key to a good result is to determine an optimal graft size. An inappropriately small graft causes endoleak. The aorta may be depicted as elliptical in the CT images, either scanned obliquely or really deformed. Simultaneous display of orthogonal views was helpful to obtain a real short-axis view. In the transcatheter procedures, a graft of 10% to 20% or 2 to 3 mm larger in size than the aortic diameter is commonly used so that the graft presses against the aortic wall firmly enough to be fixed. In our procedures, however, a graft of only 1 or 2 mm larger in size than the aortic diameter was mainly used because the graft is sutured to the aorta at the proximal side, and minimal expansion enough to eliminate endoleak is needed. Consequently, the results were acceptable with regression of excluded lumen, except in patient 6. In this patient aortic diameter was underestimated because it was measured at the top of the atheromatous plaque. This experience led us to measure the diameter at the layer of the tunica media.
The second key is safe and reliable procedures with TEE navigation. They are no longer blind manipulations. However, it is essential for the surgeon and TEE operator to collaborate, and a learning curve is present. The TEE operator needs to know the procedures and visualize the events without delay. The surgeon needs to understand the characteristic images of catheters; that is, the entire portion is not depicted, but only its surface is depicted as echogenic. 5 The images are cross-sectional, and anything out of the scanning plane is not visualized. Until real-time 3-dimensional TEE becomes available, simultaneous display of transverse and longitudinal views is helpful. It depicts short- and long-axis views of graft and instruments and spares time to switch the scanning planes. One can watch either or both views as needed.
There is no criteria on how deeply the graft can be safely advanced without an occurrence of paraplegia or how long the attachment portion should be to avoid endoleak. From our initial experience in this series, we would recommend placing the graft 9 cm or longer from the diaphragm (around Th9 level) and keeping an attachment portion longer than 4 cm because we obtained an acceptable result as long as these criteria are met.
Another feature of TEE is intraoperative assessment. The intraoperative TEE findings on thromboexclusion-endoleak were predictive to the prognosis. When aneurysm or false lumen is successfully thromboexcluded, it regresses and even disappears in the midterm follow-up period. The leakage at the proximal suture and graft kinking was rather overestimated or might have alleviated by the time of postoperative assessment.
We conclude that TEE facilitates surgical endovascular stent grafting, especially in determining the graft size, navigating endovascular procedures, and assessing the results immediately after these procedures. Intraoperative assessment is predictive of the postoperative result.
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References |
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