J Thorac Cardiovasc Surg 2005;129:1206-1207
© 2005 The American Association for Thoracic Surgery
Single-stage repair of extensive thoracic aortic aneurysms
Carmine Minale, MD
Cardiovascular Department, Division of Cardiovascular Surgery, Ospedale San Carlo, Potenza, Italy
To the Editor:
I congratulate Dr Kouchoukos and colleagues1 for their excellent results with the single-stage repair technique of extended thoracic aortic aneurysms. We originally introduced this technique2 in 1994 with a limited series of 16 patients and a hospital mortality of 12.5%. Ten years ago axillary artery cannulation, branched arterial grafts, and antegrade cerebral perfusion were not routinely used. As a consequence, cerebral ischemia was longer than today, and patients had to undergo operation with deep hypothermia and circulatory arrest. In our first series cerebral ischemia averaged 55.7 minutes. A further consequence of deep hypothermia was more frequent respiratory complications than observed today. During recent years, we also improved our technique by adding antegrade cerebral perfusion, either through retrograde axillary artery perfusion or the "aortic arch (or branch) first" technique, as suggested by Dr Kouchoukos and colleagues.1 Body temperature is generally decreased to no more than 25°C. Our series now includes approximately 53 patients with an overall hospital mortality of 9.4%. Among the last 30 patients, hospital mortality was 6.7%; neurologic and respiratory complications accounted for 3.3% and 6.7%, respectively. In regard to the "clamshell" access, we still use an approach through a limited right anterior thoracotomy through the third intercostal space and an anterolateral left thoracotomy through the fourth intercostal space with the patient banked 45 degrees on the right side. In our opinion, this access gives an easier approach to the aortic root along with the arch branches and to the most distal portion of the thoracic aorta. Reimplantation of lower intercostal arteries is not a problem in this way. Contrary to some of Dr Kouchoukos discussants, I fully agree with the author on the strategy of the single-stage approach in complex cases of thoracic aortic aneurysms. This often is the case in patients who have undergone operation for acute type A aortic dissection, in whom the aortic valve had been repaired and the ascending aorta had been replaced by a tube graft, even though it was extended in some cases to a proximal hemiarch. In such acute instances, the Bentall or equivalent techniques will not be used universally, and the elephant-trunk technique will be used even less. A common late observation in such cases is aneurysm development in the aortic root, often associated with valve incompetence, and distal part of the arch and descending aorta. Conventionally, the treatment of these patients would include a repeat sternotomy with Bentall or valve-sparing procedures, arch replacement with the elephant-trunk technique, and followed later by a second procedure with replacement or endostenting of the descending portion of the aorta whenever possible. Actually, endovascular stenting of the descending aorta is not always a guarantee against secondary disruption or leakage. Except for the discomfort experienced by the patients, the cumulative risk for the multiple-stage approach can reasonably be presumed to be higher than that reported by Dr Kouchoukos et al and ourselves for the single-stage approach. For these reasons I strongly recommend Dr Kouchoukos and colleagues’ suggestions to trust the single-stage techniques in selected cases whenever indicated.
References
- Kouchoukos NT, Mauney MC, Masetti P, Castner CF. Single-stage repair of extensive thoracic aortic aneurysms. experience with the arch-first technique and bilateral anterior thoracotomy. J Thorac Cardiovasc Surg 2004;128:669-676.[Abstract/Free Full Text]
- Minale C, Splittgerber FH, Wendt G, Messmer BJ. One-stage intrathoracic repair of extended aortic aneurysms. J Card Surg 1994;9:604-613.[Medline]
