Abstract
BackgroundTreatment of complex aortic pathologies involving the transverse arch with extensive involvement of the descending aorta remains a surgical challenge. Since clamshell incision provides superior exposure of the entire thoracic aorta, we evaluated the use of this technique for single-stage total arch replacement by arch vessel reconstruction.MethodsThe arch-first technique combined with clamshell incision was used in 38 cases of aneurysm and aortic disease in 2008 and 2009. Extensive total arch replacement was used with clamshell incision for reconstruction of arch vessels under deep hypothermic circulatory arrest.ResultsOverall 30-day mortality was 13%. The mean operating time was approximately 8 hours. Deep hypothermia resulted in mean CPB time exceeding 4.5 hours and mean duration of circulatory arrest was 25 minutes. The overall postoperative temporary and permanent neurologic dysfunction rates were 3% and 3% for elective and 3% and 0% for emergency surgery, respectively. All patients except the five who died in hospital were discharged without nursing care after an average post-operative hospital stay of 35 days.ConclusionsThe arch-first technique, combined with clamshell incision, provides expeditious replacement of the thoracic aorta with an acceptable duration of hypothermic circulatory arrest and minimizes the risk of retrograde atheroembolism by using antegrade perfusion.
Highlights
The treatment of complex aortic pathologies involving the transverse arch with extensive involvement of the descending aorta remains a surgical challenge because distal anastomosis is often impossible through conventional median sternotomy [1,2,3]
The technique described in the previous section was used for 38 patients undergoing total arch replacement (Table 1)
Of the patients treated with elective surgery, one died postoperatively of multiple organ failure due to shaggy aorta syndrome which developed during repair of an aneurysm
Summary
The treatment of complex aortic pathologies involving the transverse arch with extensive involvement of the descending aorta remains a surgical challenge because distal anastomosis is often impossible through conventional median sternotomy [1,2,3]. Several techniques have been used to overcome this challenge and these include: additional thoracotomy, the elephant trunk technique (both classical and frozen), the pull-through technique with posterior pericardiotomy, and staged repair [4,5,6]. Another option is proximal anastomosis with posterolateral thoracotomy, which is a popular surgical approach for Stanford type B aortic dissection [7]. Since clamshell incision provides superior exposure of the entire thoracic aorta, we evaluated the use of this technique for single-stage total arch replacement by arch vessel reconstruction
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