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Anastomosis Technique For Mini-total Arch Replacement Via Partial Sternotomy
Yosuke Takahashi, Takashi Murakami, Hiromichi Fujii, Masanori Sakaguchi, Shinsuke Nishimura, Daisuke Yasumizu, Yoshito Sakon, Toshihiko Shibata.
Osaka City University Graduate School of Medicine, Osaka, Japan.
OBJECTIVE: A narrow surgical field requires a reliable anastomosis technique that preclude bleeding. The purpose of this presentation was to report a reliable both distal and proximal anastomosis in total arch replacement using open-stent graft via upper partial sternotomy.
METHODS: There were 3 cases of total arch replacement using open-sent from April 2016 to August 2016. We performed an inverted T-shaped upper partial sternotomy with an average of 10.5 cm skin length. Partial sternotomy was made from juglar notch to the fourth intercostal space. Cardiopulmonary bypass was initially established with ascending aortic cannulation and venous return from femoral vein. During cooling, the ascending aorta was cross-clamped and cardiac arrest was obtained. Using separate graft, proximal anastomosis was made first. The inverted graft was inserted into the proximal stump, and two layers of sutures, using horizontal mattress and over-&-over sutures, were made with external felt strip. At the cranial temperature of 25°C, under circulatory arrest and selective antegrade cerebral perfusion, open stent graft was inserted to the descending aorta. Transected stump of the aortic arch was reinforced by external felt strip and internal open stent-graft at 4 points fixation. Distal anastomosis with 1-branched graft was made using stepwise technique using horizontal mattress and over-&-over sutures. Finally, distal and proxymal graft were anastmosed. After aortic declamping, reconstruction of neck vessels was performed.
RESULTS: Average aortic cross clamp time and circulatory arrest time were 104 minutes and 50 minutes, respectively. The levels of distal end of the stent were Th 6, Th7, and Th 8, respectively. In all cases, bleeding from both distal and proximal anastomosis was not recognized. Postoperative CT showed neither Type I nor II endoleak, and we obtained complete thrombosis of the aneurysm in all cases. The blood transfusion during surgery was an average of 7 units.
CONCLUSIONS: Our distal and proximal anastomosis techniques enables a reliable hemostasis and reproducible procedures. Our techniques were especially useful at partial sternotomy with limited surgical field.
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