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J Thorac Cardiovasc Surg 2001;121:1223-1224
© 2001 The American Association for Thoracic Surgery

Letters to the Editor

Distal anastomotic site of extra-anatomic aortic bypass through a sternotomy for complex aortic arch obstruction

Division of Cardiovascular Surgery
Keio University
Tokyo, Japan

To the Editor:

We read with interest the recent article by Kanter and associates ¹ regarding extra-anatomic aortic bypass grafting from the ascending to the descending aorta. We thoroughly agree with their conclusion that extra-anatomic bypass grafting via sternotomy is a surgical option for selected patients with complex and/or recurrent aortic arch obstruction. However, the optimal distal anastomosis site should be determined after further consideration. At Keio University, we ² preferentially select the supraceliac abdominal aorta as the optimal distal anastomosis site after an extension of a median sternotomy and a small upper laparotomy, as originally described by the Texas group, ³ for the following reasons.

First, in extra-anatomic bypass grafting, the esophagus is at risk (1) of injury from the surgical procedure itself and (2) of contact with and rubbing against the tube graft, which leads to late erosion and the development of aorto-esophageal fistula. Consequently, avoiding these complications is the first priority. The esophagus lies on top of the aorta above the diaphragm, running leftward and posteriorly as it nears the stomach (and the aorta runs from the left to the median and the posterior to the anterior). We advocate that a safer surgical procedure at the distal anastomosis, including aortic dissection, involves the placement of a vascular clamp and tube graft in a right anterior oblique direction from the right side of the esophagus at the supraceliac abdominal aorta. More important, the margin of the esophagus before dissection can be more easily identified by digital palpation of the stomach tube through the thin posterior peritoneum rather than through the thick pericardium.

Second, compression of the right coronary artery and its branch by the tube graft is a potential complication even late after the procedure because of the tethering effect, especially in growing patients. In extra-anatomic bypass grafting to the supraceliac abdominal aorta, the diaphragm can serve as a cushion and a longer tube graft can be accommodated without kinking to protect the right coronary artery and to avoid tethering.

We believe these advantages of extra-anatomic bypass grafting to the supraceliac abdominal aorta outweigh the only disadvantage—the need for an additional laparotomy.

12/8/114775doi:10.1067/mtc.2001.114775

References

1. Kanter KR, Erez, E, Williams WH, Tam VKH. Extra-anatomic aortic bypass via sternotomy for complex aortic arch stenosis in children. J Thorac Cardiovasc Surg 2000;120:885-90.[Abstract/Free Full Text]
   
2. Katogi T, Aeba R, Ueda T, Nakamichi S, Takeuchi S, Kawada S. Extra-anatomic aortic arch bypass for congenital anomaly: indications, techniques and outcome. Cardiovasc Eng 1998;2:32-5.
   
3. Wukasch DC, Cooley DA, Sandiford FM, Nappi G, Reul GJ Jr. Ascending aorta–abdominal aorta bypass: indications, technique, and report of 12 patients. Ann Thorac Surg 1977;23:442-8.[Abstract]
   

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Ryo Aeba Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Aeba, R. Articles by Kawada, S. Search for Related Content PubMed PubMed Citation Articles by Aeba, R. Articles by Kawada, S. Related Collections Great vessels