Case Reports The following case reports illustrate some of the ways in which staplers have proved useful in operations for aneurysms of the aorta.

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1 Use of Stapling Instruments in Surgery for Aneurysms of the Aorta M. Arisan Ergin, M.D., James V. O'Connor, M.D., Carlos Blanche, M.D., and Randall B. Griepp, M.D. ABSTRACT Since their inception, surgical stapling devices have been used almost exclusively in pulmonary and gastrointestinal procedures. We present our experience with surgical staplers in operations for aneurysms of the aorta. Three illustrative case reports are presented that demonstrate the applicability of surgical stapling devices in excluding aortic aneurysms. Seven patients have undergone operation using this technique, all with excellent technical results. We believe that surgical stapling devices represent a safe, easy, and rapid means of excluding aneurysms of the aorta. Surgical stapling instruments were introduced to western surgical circles by Androsov in the mid-1950s [I, 21. Since then, a number of refinements have yielded the simple and reliable devices that are currently available. Because stapling instruments can place staples quickly and safely, they have been used with increasing frequency in gastrointestinal and pulmonary procedures during the last decade [3]. In vascular operations, however, the use of staplers has been limited to closure of the pulmonary artery and veins during pneumonectomy; occasionally they have also been used to provide vena caval plication. This report details the successful use of stapling instruments in operations for aneurysms of the aorta where speed is one of the cardinal requirements for a successful outcome. Technical Considerations We have used the TA line of staplers exclusively.* We have chosen to buttress the staple From the Division of Cardiothoracic Surgery, Department of Surgery, State University of New York, Downstate Medical Center, Brooklyn, NY. Accepted for publication Oct 19, Address reprint requests to Dr. Ergin, Department of Surgery, Box 40, Downstate Medical Center, 450 Clarkson Ave, Brooklyn, NY 'U.S. Surgical Corp., Norwalk, CT lines in the aorta with a thin sheet of USCI Teflon cloth to strengthen friable aortic tissue. The portion of the aorta to be stapled requires only minimal dissection to allow placement of the stapler. The Teflon cloth is secured temporarily to the jaws of the stapler utilizing several 6-0 Prolene sutures (Fig 1A). Just prior to placement of the stapler, the aorta is rendered flaccid with cardiac inflow occlusion, proximal cross-clamping, or pharmacologically induced hypotension using sodium nitroprusside. Then the stapler is put in place and tightened down, and the staples are fired (see Fig 1). As the stapler is removed, the 6-0 Prolene sutures attaching the Teflon cloth to the stapler usually break away easily; if not, they can be divided with a blade. Normal blood pressure is restored. Case Reports The following case reports illustrate some of the ways in which staplers have proved useful in operations for aneurysms of the aorta. Putient 1 A 64-year-old man was seen with substernal and dorsal chest pain. He had also noticed the onset of hoarseness approximately three weeks before his admission. His past medical history was notable for heavy cigarette smoking (80 pack-years). On physical examination, he was a normally built man in moderate distress due to pain. Blood pressure was 180/90 mm Hg, pulse was 110 beats per minute and regular, and temperature was 37.2"C. Electrocardiogram showed left ventricular hypertrophy. Arterial blood gases showed resting hypoxemia with a partial arterial oxygen tension of 56 mm Hg (on room air), a partial arterial carbon dioxide tension of 46 mm Hg, and a ph of Chest roentgenogram taken on admission to the hospital showed a large mass occupying the upper left hemithorax and obscuring the aortic knob. Aortography demonstrated a huge aneurysm, presumably atherosclerotic, arising from the base 161

2 162 The Annals of Thoracic Surgery Vol 36 No 2 August 1983 A B \ Fig 1. (A) The T A 90 and TA 55 staplers with the Teflon cloth temporarily attached in preparation for in-continuity stapling of the aorta. (B) The TA stapler positioned around the aorta. Note the reinforcing sheet of Teflon cloth. (C) Cross-sectional view of staple closure of the aorta. The aortic layers are sandwiched between the Teflon sheet and the double row of staples. C of the aortic arch and terminating in a normalsized descending aorta. Because of his marginal pulmonary reserve, the patient was thought to be a poor risk for standard resection through a thoracotomy. Also, the sheer size of the aneurysm and its proximity to the aortic arch would have made this approach technically difficult. Therefore, it was decided to exclude the aneurysm with the aid of surgical stapling. The ascending aorta, the heart, the arch of the aorta and its branches, and the proximal aneurysm in the left chest were exposed through a median sternotomy with extension into the epigastrium. A 35 mm woven graft was used for

3 163 Ergin et al: Stapling in Surgery for Aortic Aneurysms an ascending aortic-supraceliac aortic bypass. Then the dissection around the arch of the aorta was carried out and the origin of the aneurysm stapled at this point with a TA 90 stapler (4.8 mm staples) using inflow occlusion. The distal descending aorta was dissected transpericardially with the aid of two short periods of inflow occlusion. After circumferential isolation of the descending aorta, the TA 55 stapler (4.8 mm staples) was used to staple the aorta in continuity, completing the exclusion of the aneurysm. As expected, the patient s postoperative course was complicated by respiratory failure, which gradually resolved with proper treatment. He was discharged after having a postoperative aortogram one month later (Figs 2, 3). The use of staples to exclude this large aneurysm provided an excellent solution to a formidable surgical problem. Stapling of the aorta just distal to the aortic arch was possible with only minimal dissection to allow the safe placement of the blades of the TA 90 instrument around the aorta without blood loss. Blunt dissection of the descending aorta through the posterior pericardium is safe, expeditious, and easy. Application of the staples in this area completes, the exclusion of the aneurysm. Short periods of inflow occlusion permit this maneuver to be carried out under direct vision with retraction of the nondistended heart. The use of staples made this aneurysmal exclusion possible, whereas conventional clamping and suturing techniques would have been time-consuming and hazardous, and would have led to excessive bleeding. Putien t 2 In a 47-year-old man who was initially admitted because of bilateral pneumonitis, a mycotic aneurysm of the aortic arch developed. An aortogram showed a bosselated aneurysm arising from the inferior surface of the aortic arch. The aneurysm occupied most of the upper mediastinum, pushing the left main bronchus inferiorly. Despite appropriate antibiotic therapy, the aneurysm enlarged at an alarming rate and urgent resection was deemed mandatory. The primary logistical problems in surgical planning for this patient were (1) the need to place prosthetic bypass grafts without having them con- Fig 2. Postoperative chest roentgenogram (Patient 1). Note the location and size of the aneurysm that was excluded. taminated by aneurysmal contents and (2) the need to avoid manipulation of the aneurysm itself in order to minimize the risk of embolization. A median sternotomy with extension to the left neck was used to provide wide exposure of the ascending aorta, aortic arch, and branches. After an ascending aortic-supraceliac aortic bypass graft was placed, grafts were placed from this graft to the innominate, left carotid, and left subclavian arteries. Staples were used to close and divide the arch vessels flush with the aortic arch. After all grafts were in place, the ascending aorta was stapled with a TA 55 stapler just distal to the takeoff of the ascending aorticsupraceliac aortic graft and divided expeditiously. Thus, the aneurysm and the aortic arch were completely excluded from the proximal circulation without manipulation. The sternotomy was closed. A left thoracotomy was performed and the infected aneurysm removed after the thoracic aorta was stapled distal to the aneurysm (Fig 4). The patient recovered satisfactorily without evidence of circulatory difficulties or graft infection. The use of staples in this patient greatly facilitated a lengthy and difficult procedure. Di-

4 164 The Annals of Thoracic Surgery VoI 36 No 2 August 1983 A B Fig 3. (A) Exclusion of the aneurysm and the ascending aortic-supraceliac aortic bypass graft. Note the location of the staple lines as reference for the postoperative aortograms. (B) Postoperative aortogram demonstrating the ascending aortic-supraceliac aortic bypass graft and both staple lines excluding the aneurysm. (C) Note the large size of the aneurysm and the proximal staple lint:. C

5 165 Ergin et al: Stapling in Surgery for Aortic Aneurysms aorta just proximal to the aneurysm and a Dacron graft was anastomosed to this area. The aorta just distal to the anastomosis was then stapled with a TA 55 stapler. The graft was clamped, the aneurysmal aorta was opened, and the vessels to the abdominal viscera were anastomosed to the graft in the manner described by Crawford and colleagues [4]. Following restoration of the flow to the abdominal viscera, the distal graft-aorta anastomosis was carried out. The patient had an uneventful recovery. The construction of the proximal anastomosis with a sidebiting clamp allows this portion of the procedure to be done without visceral ischemia. Rapid, secure staple closure of the descending aorta above the aneurysm just distal to the end-to-side anastomosis enables carrying out the visceral anastomoses without delay, resulting in short visceral ischemic time. Fig 4. The final result in Patient 2. Note the multiple extraanatomical bypass grafts reconstructing the circulation to the arch vessels as well as the abdominal aorta. The mycotic arch aneurysm was removed after staple closure of the proximal (a) and distal (b) aortic ends. vision of the arch vessels flush with the aortic arch was expedient, enabling the quick and easy performance of the distal anastomoses. Division of the ascending aorta was made simple in a tight spot after the vessel was stapled. Secure closure, of the ascending aorta was possible without extensive dissection for the application of clamps and suturing, which would have required extensive manipulation of the aneurysm. Finally, the removal of the aneurysm, through a left thoracotomy following distal stapling, was a very simple matter. The use of a stapling technique in this patient saved time, energy, and blood in a lengthy and complicated procedure. Patient 3 A 62-year-old woman who had had aortic valve replacement and coronary artery bypass grafting was seen with a large thoracoabdominal aneurysm. A standard thoracoabdominal retroperitoneal approach to the aorta was used. A sidebiting clamp was placed on the descending Comment Stapling instruments are especially suitable for in-continuity exclusion of difficult aneurysms of the aorta. In the first case report presented, such a patient is described. The exclusion principle has been revived recently by Carpentier and associates [5]. They have used specially made clamps for closure of the aorta above and below the aneurysm. We found that staples do the same job safely. Staples are universally available and applicable, and they accommodate any size aorta one may encounter, such as the proximal exclusion staple line in Patient 1. Moreover, the staple line is flexible, and late erosion, rupture or migration seem less likely than with a permanent rigid clamp. Recently, Carpentier [6] has pointed out one such complication of the permanent clamp. In Patient 2, the division of the ascending aorta was simplified by the ability to use the stapler in an area where access was difficult. Use of clamping and suturing techniques in this patient would have been almost impossible if manipulation of the aneurysm were to have been avoided. The technical innovations of Crawford s group [4] in the treatment of thoracoabdominal aneurysms represent an invaluable advance in the management of these difficult situations. The key to a successful outcome in utilizing this technique is to perform an

6 166 The Annals of Thoracic Surgery Vol 36 No 2 August 1983 expeditious operation; measures that reduce visceral ischemic time are important. The report of Patient 3 illustrates the use of stapling for this purpose. This modification of the technique of Crawford and co-workers shortens visceral ischemic time by about ten minutes and is our method of choice if there is sufficient nondiseased descending aorta available for application of a sidebiting clamp. The techniques we have described in these case reports have been used in 9 patients. In all 9, the technical results of stapling the aorta were satisfactory. If one adheres to the principles we have outlined, consistently reliable results should be expected with the use of the stapling instruments. We believe that with experience, this new use for such instruments will find wider application in surgery for aneurysms of the aorta. References 1. Androsov PI: New method of surgical treatment of blood vessel lesions. AMA Arch Surg 73:902, Androsov PI: Operations in cases of aneurysms. AMA Arch Surg 73:911, Ravitch MM, Steichen FM: Technics of staple suturing in the gastrointestinal tract. Ann Surg 175:815, Crawford ES, Snyder DM, Cho GC, Roehn JOF: Progress in the treatment of thoraco-abdominal and abdominal aortic aneurysms involving celiac, superior mesenteric and renal arteries. Ann Surg 188:404, Carpentier A, DeLoche A, Fabiani JN, et al: New surgical approach to aortic dissection: flow reversal and thromboexclusion. J Thorac Cardiovasc Surg 81:659, Carpentier AF: Discussion of Bachet J, Gigou F, Laurian C, et al: Four-year clinical experience with the gelatin-resorcine-formol biological glue in acute aortic dissection. J Thorac Cardiovasc Surg 83:212, 1982