Ascending Aorta Replacement by Minimally Invasive Technique

This video describes the authors' preferred approach to performing an ascending aorta replacement using a minimally invasive technique. The case involves a fifty-three-year-old male with a past medical history of hypertension and an ascending aorta aneurysm with increased diameter during follow up. A preoperative study showed a normally functioning bicuspid aortic valve and a nondilated aortic root.

The authors’ preferred approach for replacing the ascending aorta is a J-shaped partial upper sternotomy in the fourth intercostal space. To achieve better exposure of the supra-aortic vessels, surgeons employed a self-retaining retractor.

This was followed by opening the pericardium and mobilizing the innominate vein, the brachiocephalic trunk, and the left carotid artery. The brachiocephalic and the left carotid artery were isolated and surrounded with elastic tapes. To optimize aortic exposure, the pericardium was lifted and held between the sternum and the retractor blades.

In order to establish arterial inflow, the brachiocephalic trunk was clamped with a side biting clamp. A cross incision was then made on its anterior surface. Next, a 10 millimeter Dacron graft was anastomosed using a running 5-0 polypropylene suture.

Once the air had been removed from the circuit, the graft was connected to the arterial line of the extracorporeal circulation. Venous drainage was achieved by cannulating the svc with a single stage cannula. Surgeons used a single stage venous cannula.

Next, cardiopulmonary bypass was started. Temperature was dropped to between 28 and 32 °C depending on the estimated time expected for arch work. The aorta was cross-clamped, followed by antegrade cardioplegia administered through a 14 G needle.

Aortic transection was then performed, and the aortic root was exposed using traction sutures at the commissures. This facilitated resecting the proximal portion of the aorta. While cooling was taking place, proximal aortic replacement was performed with a polyester graft.

Once the anastomosis was completed, cardioplegia was  administered using the 14G needle into the graft with a distal clamp to pressurize it. This maneuver was necessary to ensure that the proximal anastomosis was perfectly continent. Once the desired systemic temperature was reached, selective antegrade cerebral perfusion began with lower body circulatory arrest. The aortic cross clamp was then released. The distal ascending aorta was resected along with the arch. The distal aorta, and eventually any length of the aortic arch, were then replaced with another polyester graft.

After completing the distal anastomosis (and supra-aortic vessels if the arch was replaced) the supra-aortic clamps were released and the whole body perfusion reestablished. The aortic graft was then cross clamped and the patient was rewarmed.

Next, the distal and proximal aortic grafts were anastomosed. All of the aortic anastomoses were performed with 5-0 polypropylene. An epicardial pacing wire was then placed in the inferior wall of the right ventricle. Air was removed using a needle and the aortic cross clamp was released. Once the heart had recovered sinus rhythm and normal contractility, cardiopulmonary bypass was weaned. The venous cannula was removed and the brachiocephalic trunk graft was ligated. A drainage tube was then installed in the mediastinum and externalized through the right pleural space. Hemostasis was verified followed by sternal closure using four separate wires.

Postoperatively, the patient did well and was discharged home on postoperative day four.

References

1. Paul P. Urbanski, Aristidis Lenos, Petros Bougioukakis, Ioannis Neophytou, Michael Zacher and Anno Diegeler. Mild-to-moderate hypothermia in aortic arch surgery using circulatory arrest: a change of paradigm? European Journal of Cardio-Thoracic Surgery 41 (2012) 185–191. doi:10.1016/j.ejcts.2011.03.060
2. Paul P. Urbanski, MD, PhD, Tarvo Thamm, PhD, Petros Bougioukakis, MD, Vadim Irimie, MD, Pravin Prasad, MD, Anno Diegeler, MD, PhD, and Aristidis Lenos, MD. Efficacy of unilateral cerebral perfusion for brain protection in aortic arch surgery. J Thorac Cardi- ovasc Surg 2019;1-7. doi.org/10.1016/j.jtcvs.2019.02.039

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