Dacron Graft Double Inversion for Ascending Aorta Surgery

Aneurysm and dissection are among the most prevalent conditions that impact the ascending aorta (1). The standard treatment approach for these issues is graft replacement, a surgical procedure that has consistently demonstrated outstanding outcomes in both the short and long term (2). 

In particular, when the problem is localized to the ascending aorta and the sinuses of Valsalva remain intact, which is often the case in ascending aortic aneurysms, a specialized procedure known as supracommissural aortic replacement is performed (3). This technique involves removing the affected section of the ascending aorta while preserving the sinuses to ensure that the aortic valves remain functional. This surgery can be enhanced with aortic valve replacement or either partial or complete arch replacement (3).

The procedure entails the excision of the ascending aorta at the designated level, followed by the careful construction of a Dacron graft. The graft could be bevel-shaped for hemiarch reconstruction or oriented transversely for an interposition tube graft. The graft inversion technique facilitates a more efficient surgical process while adequately addressing the imperative aspects of respecting the aortic root anatomy. 

The authors' approach to replacing the ascending aorta began with a complete sternotomy, although a mini sternotomy is often preferred. The brachiocephalic and left carotid arteries were isolated to serve as sites for arterial cannulation and potential cerebral perfusion before the pericardial opening. Cardiopulmonary bypass was then initiated. The aorta was cross-clamped, and cardioplegia was administered. A proximal aortic transection was performed, ensuring sufficient distance from the coronary ostia for proper suturing. Initially, the graft fabric was completely inverted, and the properly sized graft was inserted into the left ventricle, ensuring correct positioning at the edges of the proximal aortic stump. Before suturing, the surgeons reinverted a 1 cm height of fabric material inside the graft to serve as a collar of the proximal suture site. 

The graft was carefully advanced into the left ventricle through a native aortic valve, ensuring that it was properly positioned and avoiding any damage to the leaflets. This maneuver was also possible through a bioprosthetic valve. Efforts were made to gently preserve a cylindrical contour to preserve or improve leaflet coaptation. The sutures were reinforced with extra Teflon felt on the outside to ensure stability. 

The needle bite involved the two layers of the tube graft, aortic wall, and a Teflon felt strip. This method not only enhances the connection but also promotes a more effective hemostatic response. Ultimately, the reversed fabric portion was retracted, causing the inner collar to become external, and the Dacron graft returned to its original configuration. Following the distal anastomosis, with or without partial or complete arch replacement, the patient was gradually weaned from cardiopulmonary support. 

This modified technique may offer significant benefits for older patients and those managing comorbidities. By using a supracoronary suture, the aortic root can be reshaped, potentially reducing the time spent in surgery. This approach optimizes the graft's performance, ensuring that it integrates seamlessly with the native aortic structure and enhances the functionality of the aortic valve (4, 5, 6). 

References

1. Cira Rosaria Tiziana di Gioia , Andrea Ascione , Raffaella Carletti and Carla Giordano.Thoracic Aorta: Anatomy and Pathology. Diagnostics 2023,13,2166.https://doi.org/10.3390/diagnostics13132166
2. Ryan R. Davies, Lee J. Goldstein, Michael A. Coady, Shawn L. Tittle, John A. Rizzo, Gary S. Kopf and John A. Elefteriades. Yearly Rupture or Dissection Rates for Thoracic Aortic Aneurysms: Simple Prediction Based on Size. Ann Thorac Surg 2002;73:17–28)
3. Igor Vendramin, Uberto Bortolotti, Davide Nunzio De Manna, Andrea Lechiancole, Sandro Sponga, Ugolino Livi, Combined Replacement of Aortic Valve and Ascending Aorta—A 70-Year Evolution of Surgical Techniques. Aorta (Stamford) 2021; 9:118–123
4. Morimoto N, Matsumori M, Tanaka A, Munakata H, Okada K, Okita Y. Adjustment of sinotubular junction for aortic insufficiency secondary to ascending aortic aneurysm. Ann Thorac Surg. 2009 Oct;88(4):1238–43.
5. David TE, Feindel CM, Armstrong S, Maganti M. Replacement of the ascending aorta with reduction of the diameter of the sinotubular junction to treat aortic insufficiency in patients with ascending aortic aneurysm. J Thorac Cardiovasc Surg 2007;133:414–8.
6. Tataroglu C, Cenal AR, Tekumit H, Uzun K, Polat A, Akinci E. Reduction of the sinotubular junction in patients undergoing ascending aortic replacement with coexisting aortic insufficiency. J Card Surg. 2011;26:88–91

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