HOW TO DO IT. Intraluminal Graft for Acute Dissection of the Ascending Aorta

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1 HOW TO DO IT Intraluminal Graft for Acute Dissection of the Ascending Aorta Hendrick B. Barner, M.D., and Vallee L. Willman, M.D. ABSTRACT A technique of intraluminal graft placement for the management of acute dissecting aneurysm of the ascending aorta is described. Acute dissecting aortic aneurysm is associated with early death due to intrapericardial rupture or acute aortic insufficiency, and it requires prompt o rative intervention. A simple technical approach excludes the intimal tear, o r literates the false lumen proximally and distally, and achieves resuspension of prolapsed aortic cusps which others have shown to be of long-term durability. A cute dissection of the ascending aorta (Types I and 11) [6] is associated with a high mortality, whether untreated [7-91 or treated nonoperatively [5, 61. It has become evident that Type I and I1 lesions, in contrast to those of Type 111, should be managed operatively. With the advent of cardiopulmonary bypass, the ascending aorta with a dissecting aneurysm was resected and replaced with a homograft [2]. Subsequently, synthetic grafts were used [el. A more aggressive approach has since evolved, and frequently the aortic valve is replaced in patients having acute aortic insufficiency associated with acute dissection [lo]. Others do not use aortic valve replacement in this circumstance, relying on resuspension of the cusps to achieve a competent valve [l, 5, 11, 121. This report describes a simple method of intraluminal graft placement which was recently used in 2 patients with acute dissection and aortic insufficiency. PATIENT 1 A 47-year-old woman was hospitalized 36 hours after a sudden, snapping sensation was experienced in the upper anterior thorax followed by From the Department of Surgery, Saint Louis University School of Medicine, St. Louis, Mo. Supported in part by Grant HL from the National Heart and Lung Institute, National Institutes of Health. Accepted for publication June 5, Address reprint requests to Dr. Barner, 1325 S. Grand, St. Louis, Mo THE ANNALS OF THORACIC SURGERY

2 HOW TO DO IT: Zntraluminal Graft for Aortic Dissection persistent pain of moderate severity in the upper chest and neck. Five years previously she had undergone resection of a dissecting thoracic aortic aneurysm (Type 111). At the time of the current admission she was hemodynamically stable and not in acute distress. A Type I1 dissection with moderate aortic insufficiency was identified by retrograde left heart catheterization. At operation 48 hours after admission a 1 cm. stellate intimal laceration was found just above the noncoronary cusp, and another 2.5 cm. transverse intimal laceration was found centered posteriorly on the right 1.5 cm. distal to the stellate laceration. Circumferential dissection of the ascending aorta extended into the noncoronary sinus of Valsalva proximally and an unknown distance distally. The postoperative course following intraluminal graft placement was free of complications, and she was dismissed from the hospital eleven days following operation. PATIENT 2 A 68-year-old man without a history of hypertension had an acute onset of chest pain. There was transient aphasia and paralysis of the left arm which was followed by prompt, complete resolution. On admission to the hospital the blood pressure was 60 mm. Hg systolic and rose to 100/60 with an infusion of isoproterenol. Six hours after admission a retrograde left heart catheterization study confirmed the clinical impression of ascending aortic dissection with acute aortic insufficiency. Six hours later, gradual hemodynamic deterioration and anuria led to operation. At operation there was a 1 cm. intimal laceration 2 cm. distal to the noncoronary cusp with circumferential dissection of the ascending aorta. The dissection extended into the noncoronary sinus of Valsalva and involved the commissure between the right and noncoronary cusps. Postoperatively following intraluminal graft placement there was a fiveday interval of high-output renal failure followed by return of normal renal function. Pseudomonus pneumonia occurred, necessitating a tracheostomy for respiratory support, and therapy was necessary to control persistent hypertension. The patient died suddenly forty days after operation. Postmortem examination did not reveal a specific cause of death, and the aortic reconstruction was intact. Method Cardiopulmonary bypass with moderate hemodilution and moderate hypothermia is instituted with pump return to a femoral artery. The heart is packed in crushed ice made from Ringer's lactate solution. The aorta is crossclamped at the innominate artery, and a longitudinal incision is made in the ascending aorta (Fig. 1). The position of the intimal tear is confirmed (it is

3 BARNER AND WILLMAN FIG. 1. A longitudinal aortotomy provides exposure for intraluminal graft placement. The proximal suture line is completed first and lies in the plane just distal to the commissures. usually several centimeters distal and posterior to the valve), and the aortic valve is inspected. A knitted or woven Dacron prosthesis of appropriate size is selected and placed in the aortic lumen. Two strips of Teflon felt are placed outside the aorta, and the suture line is begun posteriorly on the right side by placing a mattress suture of 4-0 Dacron just above the plane of the commissures and through the graft, aorta, and felt; the suture is then tied outside the aorta (see Fig. 1). This suture is continued to the right as a running mattress suture. The suture line to the left of the posterior mattress suture is begun as a running suture within the lumen, taking a double thickness of the aortic wall with each bite until a point is reached at which access can be gained to the external aspect of the aorta between the aorta and the pulmonary artery. This suture line is then continued as a running mattress suture placed through a second strip of Teflon felt. If more support of the cusps seems desirable, a buttressed mattress suture can be placed across the commissure(s) and tied outside the lumen. The distal suture line is performed in like fashion after suitable transection of the graft (Fig. 2). The aorta is then closed with a running everting mattress suture that includes both intima and adventitia, and this suture also may be buttressed with Teflon felt. Comment Intraluminal placement of prosthetic grafts combined with resection of intima and thrombus has been widely used in the management of abdominal aortic aneurysm [3, 41. This technique also has been applied to the thoracic 60 THE ANNALS OF THORACIC SURGERY

4 HOW TO DO IT: Zntruluminul Gruft for Aortic Disseclion FZG. 2. Both suture lines have been completed, and the aorta is closed over the prosthesis. aorta for the management of acute [lo] and chronic [13] dissection; however, the principle of leaving all layers of the aorta undisturbed without resection of the inner layers has not been described. For two years we have resected thrombus but not intima in the treatment of atherosclerotic abdominal aortic aneurysms. Because of the extreme friability of the aorta that may attend acute dissection, maximal strength is achieved by preserving all layers and by having a tube within a tube rather than a prosthetic tube linking two tissue tubes. The fundamental goals of operative therapy for dissecting aneurysm are achieved by intraluminal placement of the graft in that the intimal laceration is excluded and the false lumen is obliterated proximal and distal to the origin of the dissection. The absence of end-to-end anastomoses virtually avoids the problem of posterior leakage. The rapidity of the graft placement operation renders coronary perfusion unnecessary. Although follow-up on our 2 patients is quite brief, this experience is reported on.the basis that the graft technique is a logical extension of concepts used in other anatomical regions where immediate and long-term benefits have been demonstrated. Resuspension of the aortic cusps in acute dissection with aortic insufficiency has been associated with long-term competence of the valve [l, 5, and is far preferable to valve replacement. References 1. Austen, W. G., Buckley, M. J., McFarland, J., DeSanctis, R. W., and Sanders, C. A. Therapy of dissecting aneurysms. Arch. Surg. 95:835, Cooley, D. A., and DeBakey, M. E. Resection of entire ascending aorta in fusiform aneurysm using cardiac bypass. J.A.M.A. 162: 1158, Crawford, E. S., DeBakey, M. E., Morris, G. C., Jr., Garrett, H. E.. and VOL. 17, NO. 1, JANUARY,

5 BARNER AND WILLMAN Howell, J. F. Aneurysm of the abdominal aorta. Surg. Clin. North Am. 46:963, Creech, O., Jr. Endo-aneurysmorrhaphy and treatment of aortic aneurysm. Ann. Surg. 164:935, Daily, P. O., Trueblood, H. W., Stinson, E. B., Wuerflein, R. D., and Shumway, N. E. Management of acute aortic dissections. Ann. Thoruc. Surg. 10:237, DeBakey, M. E., Henly, W. S., Cooley, D. A., Morris, G. C., Jr., Crawford, E. S., and Beall, A. C., Jr. Surgical management of dissecting aneurysms of the aorta. J. Thorac. Cardiouasc. Surg. 49:130, Hirst, A. E., Jr., Johns, V. J., Jr., and Kime, S. W., Jr. Dissecting aneurysm of the aorta: A review of 505 cases. Medicine (Baltimore) 37:217, Hume, D. M., and Porter, R. R. Acute dissecting aortic aneurysms. Surgery 53: 122, Lindsay, J., Jr., and Hurst, J. W. Clinical features and prognosis in dissecting aneurysm of the aorta: A reappraisal. Circulation 35:880, Liotta, D., Hallman, G. L., Milam, J. D., and Cooley, D. A. Surgical treatment of acute dissecting aneurysm of the ascending aorta. Ann. Thorac. Surg. 12:582, Najafi, H., Dye, W. S., Javid, H., Hunter, J. A., Goldin, M. D., and Julian, 0. C. Acute aortic regurgitation secondary to aortic dissection. Ann. Thorac. Surg. 14:474, Shumacker, H. B. Operative treatment of aneurysm of the thoracic aorta due to cystic medial necrosis. J. Thoruc. Cardiovasc. Surg. 63:1, Singh. M. P., and Bentall, H. H. Complete replacement of the ascending aorta and the aortic valve for the treatment of the aortic aneurysm. J. Thorac. Cardiouasc. Surg. 63:218, NOTICE FROM THE SOUTHERN THORACIC SURGICAL ASSOCIATION The Twentieth Annual Meeting of the Southern Thoracic Surgical Association was held at the Galt House, Louisville, Ky., November 1-3, 1973, under the presidency of James W. Pate, M.D., of Memphis, Tenn. Officers elected for the coming year included Bert A. Glass, M.D., New Orleans, La., President; Frederick H. Taylor, M.D., Charlotte, N.C., President-Elect; James L. Alexander, M.D.. Savannah, Ga., Vice-President; James W. Brooks, M.D., Richmond, Va., Secretary-Treasurer; and J. Kent Trinkle, M.D., San Antonio, Tex., Assistunt Secretary-Treasurer, to take office as Secretary-Treasurer on November 10, Twenty-eight applicants were elected to active membership in the Association. The President s Award for the best scientific presentation given at the 1972 annual meeting was presented to Dr. J. Kent Trinkle of San Antonio, Tex. The 1974 meeting will be held at the Williamsburg Inn and Lodge, Williamsburg. Va., on November 7-9, Chairman of the Program Committee is William H. Lee, Jr., M.D., Medical College Hospital, 55 Doughty St., Charleston, S.C Chairman of the Membership Committee is George R. Daicoff, M.D., University of Florida College of Medicine, Gainesville, Fla JAMES W. BROOKS, M.D. Secre tary-treasurer 62 THE ANNALS OF THORACIC SURGERY