J Thorac Cardiovasc Surg 2001;121:1224
© 2001 The American Association for Thoracic Surgery
Reply
Kirk Kanter, MD
Division of Cardiothoracic Surgery
Emory University School of Medicine
365 Clifton Rd, NE
Atlanta, GA 30322
Reply to the Editor:
The comments by Doty are interesting. The use of an externally stented conduit is quite appealing. Routing of the conduit behind the inferior vena cava does make me somewhat concerned about compression of the right pulmonary veins by the conduit, particularly if there is any fibrotic reaction to the graft itself. This, of course, is probably of theoretical concern only. As far as reoperations are concerned, as is shown in our series, cardiac reoperation can be done quite safely. A technical point mentioned in the article is the practice of bringing a right pleuropericardial flap anterior to the graft to place tissue between the graft and the sternum so that subsequent sternal re-entry will be facilitated. In our hands, this has been satisfactory and we have had no difficulties in the few patients on whom we have needed to reoperate. Finally, because our population is pediatric, we have attempted to insert the largest practical bypass graft. Since most of our patients had severe and recurrent complex arch narrowing, our belief was that most of the flow would go through the extra-anatomic graft, as demonstrated in the postoperative angiogram in Fig 4 of our article.
1 In growing children, we did not wish to be faced with the situation of inadequate relief of the aortic arch gradient, even after extra-anatomic bypass.
I think the argument advanced by Aeba, Katogi, and Kawada is very compelling. However, so far as I can tell from personal experience and review of the literature, their concerns of esophageal erosion are completely theoretical. In all of the previously published experiences with this technique, including our experience, there has been no suggestion of this problem occurring when the distal anastomosis is performed to the supradiaphragmatic aorta. This includes a recent publication from the Mayo Clinic, reporting an additional 17 cases in which this technique was used with no evidence of esophageal problems on follow-up. 2
12/8/114774doi:10.1067/mtc.2001.114774
References
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Kanter KR, Erez E, Williams WH, Tam VKH. Extra-anatomic aortic bypass via sternotomy for complex aortic arch stenosis. J Thorac Cardiovasc Surg 2000;120:885-90.[Abstract/Free Full Text]
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Izhar U, Schaff H, Mullany C, Daly RC, Orszulak TA. Posterior pericardial approach for ascending aorta–to–descending aorta bypass through a median sternotomy. Ann Thorac Surg 2000;70:31-7.[Abstract/Free Full Text]
