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Ann Thorac Surg 2002;74:S1789-S1791
© 2002 The Society of Thoracic Surgeons
a Department of Cardiac Surgery, IRCCS Policlinico S. Matteo, University of Pavia, Pavia, Italy
b Department of Radiology, IRCCS Policlinico S. Matteo, University of Pavia, Pavia, Italy
* Address reprint requests to Dr Rinaldi, Divisione di Cardiochirurgia, I.R.C.C.S. Policlinico S. Matteo, P. le Golgi, Pavia 27100, Italy.
e-mail: m.rinaldi{at}smatteo.pv.it
Presented at the Aortic Surgery Symposium VIII, May 2–3, 2002, New York, NY.
Abstract
BACKGROUND: Ascending aortic aneurysms without dilatation of the sinuses of Valsalva are generally handled by resection and replacement with a tubular graft or by tailoring aortoplasty. We propose an alternative treatment with a direct anastomosis of the two stumps of the aorta after complete aneurysm resection through an upper J ministernotomy.
PATIENTS AND METHODS: We have applied this procedure to 45 patients. Mean age was 60.2 ± 12.1 years. Mean aneurysm diameter was 51.0 ± 8.0 mm. The skin incision averaged 6.5 cm. Two circumferential aortotomies were made: one at the level of the sinotubular junction, the other one just below the innominate artery. The two ends of the aorta were then sutured with a 3-0 Prolene running suture. In 31 cases (61%) aorta-associated valve replacement was carried out.
RESULTS: Hospital mortality was 4.4%. Mean CPB and cross-clamp times were 104 ± 71 and 68 ± 25 minutes respectively. Mean blood loss was 380 ± 300 mL. Median ventilation requirement and intensive care unit stay were 17 and 21 hours. Median hospital stay was 7 days. During the follow-up period (23.7 ± 12.3 months), 1 patient required reoperation and 2 patients died. Event-free survival is 88.4 ± 5.7 at 44 months. The surviving patients are routinely checked with ultrasonography and angio computed tomography scan. There was a very low redilatation rate (1 patient, 2.3%) and no incidence of pseudoaneurysm.
CONCLUSIONS: Complete resection of ascending aortic aneurysms with end-to-end anastomosis through an upper ministernotomy represents a feasible, safe, physiologic and cost-effective minimally invasive surgical option in cases of aneurysms with normal or nearly normal sinotubular junctions.
Aneurysms of the ascending aorta appear sometimes as a localized fusiform dilatation of the portion of the ascending aorta situated between the sinotubular junction and the innominate artery and they are generally handled by resection and replacement with a tubular graft. Tailoring aortoplasty with or without wrapping has also been proposed for mild to moderate aortic dilatation [1–3]. If the sinuses of Valsalva and the aortic arch are not involved in the dilatation, the aneurysm is due to elongation of the lateral wall of the aorta while the posteromedial wall almost maintains its original length. The heart is therefore displaced inferiorly and toward a more horizontal plane by the aneurysm.
In an approach through a ministernotomy, the pericardium is only partially opened. After resection of the aortic aneurysm, the heart recovers its original position. The two stumps of the aorta look closer than using a standard midline full sternotomy with an inverse T-shaped pericardiotomy.
From this observation we elaborated an alternative technique of ascending aorta reconstruction. After cuneiform resection of the aneurysm, the two aortic stumps are sutured together without interposition of a tubular graft. Such an operation may represent in selected cases a simple and effective solution for a moderate size ascending aortic aneurysm.
Patients and methods
The ascending aortic aneurysm is exposed through an upper J ministernotomy extended to the third or the fourth right intercostal space. The pericardium is opened and retraction stitches applied. The ascending aorta is encircled with a tape. The patient is placed on cardiopulmonary bypass (CPB) using an oval atrial cannula (DLP, Grand Rapids, MI) inserted in the right atrial appendage and an arterial return cannula inserted into the aortic arch or right femoral artery. The left ventricle is vented through the upper right pulmonary vein. The ascending aorta is cross-clamped distal to the aneurysm and opened. Cold crystalloid cardioplegia is infused into the coronary ostia.
A longitudinal aortotomy is made on the anterior aspect of the aorta. Two circumferential aortotomies are then carried out joining the previous one: the first at the level of the sinotubular junction and the second at the distal border of the aneurysm. At this stage the aortic valve replacement is performed if needed. The resulting resected wall is a cuneiform segment of the ascending aorta, which opened on the anterior aspect, assumes a typical butterfly shape (Fig 1). Finally the two ends of the ascending aorta are sutured together with a 3-0 Prolene (Ethicon, Sommerville, NJ) running suture. No foreign material except for reinforcing Teflon strips is used.
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Results are expressed as mean ± standard deviation and as frequency for the categorical variables. Univariate analysis was used to assess the importance of each variable. An event-free survival curve was estimated by the Kaplan-Meier method.
Results
Mean CPB time was 104 ± 71 minutes; mean cross-clamp time was 68 ± 25 minutes. The duration of mechanical ventilation was 28 ± 41 hours (median 17) and mean ICU stay was 24.2 ± 12 hours (median 21). Blood loss from chest tubes was 380 ± 300 mL with only 2 reexplorations for bleeding (4.5%). Surviving patients were discharged after 8.1 ± 5.1 days (median 7.0).
Hospital mortality was 4.4% (2 cases). One patient with type A dissection died because of permanent neurologic damage and another died of aortic annulus rupture caused by the insertion of an oversized prosthesis. No fatalities can be attributed to the technique used for the treatment of the aortic aneurysm.
The remaining 43 patients were followed for a mean of 23.7 ± 12.3 months (range 6 to 45). A computed tomography scan of the thoracic aorta was obtained in 27 patients 16.3 months after the operation. The measurements of the reconstructed aorta showed a contained maximum aortic diameter of 40.9 ± 5.2 mm (p < 0.01 compared with the preoperative one). The remaining aorta appeared substantially shortened with a mean length (from the valvular orifice to the innominate artery) of 58.1 ± 14.4 mm (Figure 2, A and B). Furthermore, no evidence of pseudoaneurysm has been detected. Aortic redilatation was also monitored in all cases with ultrasound scans taken 17.1 months after the operation: the maximum diameter of the ascending aorta was 40.3 ± 5.6 mm (p < 0.01 compared with the preoperative one). During the follow-up period 2 other patients died: 1 of a cerebral accident and 1 of sudden death after 27 and 7 months, respectively. We observed recurrence of the aortic dilatation only in 1 patient (2.3%) who was reoperated on after 16 months because of massive aortic valve regurgitation that was not adequately corrected during the first operation. Actuarial freedom from cardiac related death and aortic reoperation at 44 months is 88.4 ± 5.7.
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Tailoring aortoplasty of moderate size ascending aortic aneurysms has been suggested in the past with good long-term results [1]. With this technique, however, only a minimal part of the diseased and thinned aortic wall is removed. The resection acts only to reduce the aortic dilatation and does not affect the elongation of the aorta caused by the development of the aneurysm. A relevant incidence of redilatation occurs in medium and long-term follow-up [4]. We describe a surgical technique for reconstruction of the ascending aorta after aneurysm resection that allows one to completely resect the diseased aortic wall and to avoid the use of a tubular graft.
This operation was designed for patients undergoing a ministernotomy approach for ascending aortic aneurysm with minor involvement of the sinotubular junction. It has already been pointed out [2] that fusiform aneurysms of the ascending aorta tend to expand away from the pulmonary artery and are accompanied by elongation of the aorta displacing the heart inferiorly and toward a more horizontal plane. While the posteromedial portion of the ascending aortic wall maintains its original length, the dilatation is mainly due to elongation of the lateral wall of the vessel. This can be observed by looking at the typical "butterfly" shape of the resected wall of the aneurysm. After cuneiform resection of an ascending aortic aneurysm through a ministernotomy, the two stumps of the ascending aorta are closer, probably because the pericardium is only partially opened and holds the heart in a more physiologic position.
Once the aneurysm has been completely resected, the insertion of a tubular graft is not always necessary. With appropriate mobilization of the aortic arch it is possible to move the distal stump down toward the aortic valve and to perform a direct anastomosis with minimal tension on the sutures. In fact suturing together two vessels with a different compliance, as in the case of prosthetic tube insertion, can cause greater tension on the anastomosis [5].
The main concerns regarding the proposed technique are possible redilatation of the aorta and the development of a pseudoaneurysm at the anastomotic site. The follow-up of these patients is still limited (23.7 ± 12.3 months) and therefore the long-term durability of this operation still needs to be demonstrated. Thus far routine checks (computed tomography and ultrasonography scans) have shown a very low redilatation rate (1 of 43; 2.3%) and no incidence of pseudoaneurysm.
In conclusion, this experience suggests that in selected cases the combination of a ministernotomic approach with resection and end-to-end anastomosis can represent an easy, inexpensive and fast operation for surgical treatment of ascending aortic aneurysms. It has many theoretical advantages: it allows a more physiologic correction, the chances of bleeding are reduced, cross-clamp time is shorter, and possibly a lower incidence of cerebrovascular complications can be expected as there is no foreign material in the bloodstream.
References
This article has been cited by other articles:
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  C. Banfi, M. Rinaldi, A. M. D'Armini, and M. Vigano End-to-End Anastomosis for Ascending Aortic Aneurysm Ann. Thorac. Surg., July 1, 2005; 80(1): 385 - 386. [Full Text] [PDF]
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 F. Robicsek, J. W. Cook, M. K. Reames Sr, and E. R. Skipper Size reduction ascending aortoplasty: Is it dead or alive? J. Thorac. Cardiovasc. Surg., October 1, 2004; 128(4): 562 - 570. [Abstract] [Full Text] [PDF]
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M. Massetti, S. Veron, E. Neri, O. Coffin, O. le Page, G. Babatasi, D. Buklas, D. Maiza, J. L. Gerard, and A. Khayat Long-term durability of resection and end-to-end anastomosis for ascending aortic aneurysms J. Thorac. Cardiovasc. Surg., May 1, 2004; 127(5): 1381 - 1387. [Abstract] [Full Text] [PDF]
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