Single Stage Retrograde Replacement of Thoracic Aorta With Aortic Valve Replacement

A 63-year-old old man was diagnosed with an aortic aneurysm by routine chest X-ray. His 2D echo showed moderate aortic regurgitation with normal LV function. A CT aortogram revealed an aortic aneurysm involving the ascending aorta, arch, and descending thoracic aorta. Coronary angiogram showed a tight ostioproximal lesion in the ramus intermedius. He was taken up for surgery.

A median sternotomy was done. A 7 mm dacron graft was attached to the right axillary artery and right femoral artery for arterial access. Arch vessels were dissected and looped. A right atrial cannulation was done using double-stage venous cannula. Cardiopulmonary bypass was initiated. A right superior pulmonary vein vent was inserted and the patient was cooled to 22 degrees centigrade. While cooling the patient, a left anterolateral thoracotomy was done and the pleural cavity was entered through the fifth intercostal space. Bypass grafting was done to the ramus intermedius using the saphenous vein. Aortic cross-clamp was applied. An aortotomy was done. A regurgitant aortic valve was found to be retracted and calcified. Custodial cardioplegia was given through coronary ostia for myocardial protection. After cooling the patient to 22 degrees centigrade, circulatory arrest was established. The innominate artery was clampled with antegrade perfusion continuing to flow through the right axillary artery. The arch of the aorta was excised. An antegrade cannula was inserted into the left common carotid artery for left-sided cerebral perfusion. The left subclavian artery was looped and snugged using cotton tape. A pericardial stay stitch was taken and the heart was pulled medially for proper exposure of the descending thoracic aorta. The inferior pulmonary ligament was divided and the lung was retracted. The descending thoracic aorta was transected at the level of the diaphragm. A distal anatomosis was done using a 26 mm Dacron graft, which was reinforced with teflon felt on the aortic side.

After de-aring, visceral perfusion was restored through the femoral arterial line. Back bleeding from the intercostal arteries was identified and closed using 4-0 prolene sutures. The graft was then brought retrograde through the aneurysm into the mediastinum. Using this technique, one can avoid injury of the phrenic and recurrent laryngeal nerve. The graft was then filled again through the femoral line for proper alignment and avoiding kind, and then clamped again. Carol’s patch was created for arch vessel anastomosis. An opening was made in the graft. Antegrade cannula in the left common carotid artery was removed and reinserted through the graft in order to avoid interference during arch anastomosis. Arch vessel anastomosis was done with teflon felt on the aortic side. De-airing of the aorta was done and total body perfusion was restored. As the arotic valve was regurgitant, cusps were retracted and calcified, and the aortic sinuses were normal, it was decided to replace the valve with a 23 mm bioprosthetic valve. The proximal end of the aorta was anastomosed to the graft and it was reinforced with teflon felt on the outer side. The top end of the vein graft was anastomosed to the neo-ascending aorta. The patient was weaned off cardiopulmonary bypass. He was shifted to the ward on postoperative day three and discharged on postoperative day nine.

The image in the video shows the incision site and healed wounds, as well as reconstructed CT images comparing preoperative and two year post-surgical status. So far, the authors have performed this procedure in 22 patients with no mortality and excellent long-term results. In their experience, patients with extensive involvement of the ascending arch and descending thoracic aorta can safely undergo this procedure with a good prognosis. A CT aortogram of this patient, 25 years after single stage replacement surgery, is shown.

References

1. Cooley DA. Retrograde replacement of the thoracic aorta. Tex Heart Inst J. 1995;22:162-165.
2. Beaver TM, Martin TD. Single-stage transmediastinal replacement of the ascending, arch, and descending thoracic aorta. Ann Thorac Surg. 2001 Oct;72(4):1232-1238.

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