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J Thorac Cardiovasc Surg 2008;135:1188-1189
© 2008 The American Association for Thoracic Surgery

Letter to the Editor

The importance of distal fixation in total arch replacement for distal aortic arch aneurysm

Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan

To the Editor:

We read with interest the article from Toda and colleagues¹ about single-stage repair of arch aneurysm. We think that total arch replacement (TAR) with the long elephant trunk (LET) in this article has some potential as an alternative treatment for thoracic aortic aneurysm; however, we cannot agree with the conclusion.

In this article TAR with an LET was applied for arch aneurysm down to the level of the tracheal bifurcation. We previously reported that the aneurysms of the aortic arch were safely accessible from the midsternotomy to the level of tracheal bifurcation, and furthermore, we could reach a portion 1 cm lower than the tracheal bifurcation irrespective of the working space, shapes of the aneurysm, and quality of the aortic wall.² TAR was safely achieved with 4 branched grafts, with a mortality of 0.8% to 6.4% and a stroke ratio of 0.84% to 3.2%.^2-4 The authors stated that 9% of patients who did not demonstrate complete thrombosis of the aneurysms required distal anastomosis through a left thoracotomy as the second operation during a relatively shorter period.¹ We think the aneurysms must be excluded completely and securely to prevent aneurysm rupture in the future.

In addition, we are concerned about whether the thrombosed space around the LET actually becomes organized and the aneurysmal wall is really decompressed. We have several patients who underwent TAR with an elephant trunk procedure and second-stage endovascular stent graft. Their aneurysms outside the graft were not opacified with contrast material on computed tomographic analysis; however, the aneurysm was enlarged during follow-up. Usui and associates⁵ reported several cases with unexpectedly enlarged arch aneurysms of the TAR with a frozen elephant trunk. They stated that anchoring the graft distal to the aneurysm was mandatory.⁵ We consider that "not enhanced" in the computed tomographic scan does not always mean "thrombosed."

Finally, TAR with an LET might interrupt the ostia of the intracostal arteries to the spinal cord and has greater risk of paraplegia than standard TAR.

There are some indications for this method, such as entire thoracic aortic aneurysms that have no distal anastomotic site, aneurysms extending too far from the tracheal bifurcation, and acute aortic dissection with entry is away from the arch vessels. However, distal fixation of the free-flowing graft to the descending aorta is mandatory during TAR or in the second-stage operation.

In conclusion, we insist that the standard TAR should be applied for the arch aneurysm down to the level of tracheal bifurcation. We would like to congratulate the authors for their contributions in this field and their excellent results.

References

1. Toda K, Taniguchi K, Hata H, Shudo Y, Matsue H, Kuki S, et al. Single-stage repair of arch aneurysms with a long elephant trunk: medium-term follow-up of thromboexcluded aneurysms. J Thorac Cardiovasc Surg 2007;134:47-52.[Abstract/Free Full Text]
   
2. Asano M, Okada K, Tanaka H, Kawanishi Y, Nakagiri K, Matsumori M, et al. Total arch replacement for aneurysm of the aortic arch: factors influencing the distal anastomosis. Interact Cardiovasc Surg 2007;6:283-287.
   
3. Ogino H, Ueda Y, Sugita T, Matsuyama K, Matsubayashi K, Nomoto T, et al. Aortic arch repairs through three different approaches. Eur J Cardiothorac Surg 2001;19:25-29.[Abstract/Free Full Text]
   
4. Minatoya K, Ogino H, Matsuda H, Sasaki H, Yagihara T, Kitamura S. Surgical management of distal arch aneurysm: another approach with improved results. Ann Thorac Surg 2006;81:1353-1357.[Abstract/Free Full Text]
   
5. Usui A, Fujimoto K, Ishiguchi T, Yoshikawa M, Akita T, Ueda Y. Cerebrospinal dysfunction after endovascular stent-grafting via a median sternotomy: the frozen elephant trunk procedure. Ann Thorac Surg 2002;74(suppl):S1821-S1824.[Abstract/Free Full Text]
   

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 Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Yutaka Okita Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Asano, M. Articles by Okita, Y. Search for Related Content PubMed Articles by Asano, M. Articles by Okita, Y. Related Collections Great vessels