J Thorac Cardiovasc Surg 2008;135:1189
© 2008 The American Association for Thoracic Surgery
Reply to the Editor
Koichi Toda, MD,
Kazuhiro Taniguchi, MD,
Takenori Yokota, MD,
Satoshi Kainuma, MD
Department of Cardiovascular Surgery, Osaka Rosai Hospital, Osaka, Japan
We would like to thank Drs Asano and Okita for their comments regarding our study,1
in which we demonstrated that the majority of arch aneurysms could be repaired with a long elephant trunk (LET) anastomosed at the base of the innominate artery without distal anastomosis in the descending aorta. They raised the issue of distal fixation of the LET in our technique. Although the proximal end of the LET is sutured at the base of the innominate artery and proximal endoleak is prevented, the distal end of the LET is not fixed, and distal endoleak is possible with our method. As demonstrated in Figure 2, C, in our article, the aneurysmal sac outside the LET was enhanced with contrast material in 9% of our patients, and they required distal fixation of the LET.
However, it is important to note that the majority (91%) of our patients did not show contrast material outside the LET, and none had expansion or rupture of the aneurysm occur during the average follow-up of 33 ± 18 months. Furthermore, it was encouraging for us to find that the nonenhanced aneurysmal sac around the LET shrank more than 5 mm in 82% of the patients and more than 10 mm in 50% at 1 year after total arch replacement with the LET, as shown in Figure 2, B, of our article. The follow-up period might not have been long enough to rule out the possibility of late expansion of a nonenhanced aneurysm, and we consider that long-term follow-up of our patients is mandatory.
In their letter they referred to their article,2 in which they insist that arch aneurysms with extension to 1 cm below the level of the carina are accessible from a median sternotomy. Interestingly, they demonstrate that an increased depth of distal anastomosis is a risk factor for prolonged distal anastomosis, even in Japanese patients, whose chest cavities are generally smaller than those in white patients.2 Based on my personal experience as a clinical fellow for 3 years in United States, I wonder how many surgeons are comfortable to do the distal anastomosis 1 cm below the level of the carina in a typical barrel-chested white patient. On the other hand, with our technique, the descending aorta in the deep posterior mediastinum does not need to be exposed, but rather only a distal anastomosis is performed in the distal ascending aorta. Because of this simplicity, we required only 23 ± 8 minutes of hypothermic circulatory arrest in the lower body to complete the insertion and anastomoses of the LET. Thus we conceive that the benefit of our technique might be even more evident in white patients with a large chest.
References
- 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]
- Asano M, Okada K, Nakagiri K, Tanaka H, Kawanishi Y, Matsumori M, et al. Total arch replacement for aneurysm of the aortic arch: factors influencing the distal anastomosis. Interact Cardiovasc Thorac Surg 2007;6:283-287.[Abstract/Free Full Text]
