In graft-replacement surgery of the ascending aorta and aortic arch, 2 separate grafts are frequently needed in order to construct a more physiologically configured aorta. We describe a new cutting method for accurate performance of graft-to-graft anastomosis.

In graft-replacement surgery of the ascending aorta and the aortic arch, 2 separate grafts are frequently used to optimize the length and orientation of the graft. In this situation, and independent of techniques used for proximal and distal anastomosis, a graft-to-graft anastomosis must be performed. To avoid kinking, obstruction, or dehiscence caused by tension, the lengths and angles of the grafts should be carefully determined before the anastomosis is performed. We describe a simple method for determining the accurate cutpoints and therefore the lengths of the grafts in aortic graft-replacement surgery.

Surgical Technique

After the distal hemiarch anastomosis has been performed with the patient under selective antegrade cerebral perfusion and mild hypothermia (28 °C), the aortic root-related procedures and graft-to-graft anastomosis are performed during rewarming. To re-create the physiologic curve of the ascending aorta without kinks or tension, the free ends of the grafts are superimposed in a crosswise fashion, to form the widest obtuse angle possible (Fig. 1A), and the grafts are cut together at their crossing point in the transverse plane (Fig. 1B). This cut produces completely opposed free edges of the 2 separate grafts, and they are ready for suturing (Fig. 1C).

Fig. 1.

Drawings show A) free ends of the grafts superimposed in a crosswise fashion, to form the widest obtuse angle (α) possible; B) the cutting of both grafts at the crossing point in a transverse plane after superimposition; and C) the final appearance of the anastomosis.

Fig. 1.

Drawings show A) free ends of the grafts superimposed in a crosswise fashion, to form the widest obtuse angle (α) possible; B) the cutting of both grafts at the crossing point in a transverse plane after superimposition; and C) the final appearance of the anastomosis.

From June 2011 through May 2014, we used this method in 39 patients (35 men; mean age, 59.2 ± 8.7 yr; age range, 26–67 yr) who underwent surgery for acute type 1 aortic dissection (6 patients) or aortic aneurysm (33 patients). All 39 had hemiarch replacement surgery. Concomitant procedures were aortic valve replacement and supracoronary aortic graft replacement in 6 patients, aortic valve repair and supracoronary aortic graft replacement in 10, the Bentall operation in 13, the David operation in 9, and the Cabrol procedure in 1. One patient needed reoperation on the first postoperative day because of hemorrhage, and one patient died after a prolonged hospitalization because of respiratory failure. The survivors were in good health at last evaluation.

Discussion

In patients whose aortic aneurysms or dissections involve the proximal aortic arch, different distal anastomotic methods have been developed by which to construct a more physiologically configured aorta with use of a single graft. However, in many patients who undergo hemiarch replacement and in all who undergo total arch replacement, 2 separate replacement grafts are used in order to avoid kinks and tension.1,2  In these patients, accurate estimation of the graft-to-graft anastomotic site is crucial, if proper length and configuration are to be attained.

Estimating graft length can be problematic. The main reasons are distortion of the aortic anatomy by the disease process itself, and natural curving of the ascending aorta and aortic arch that results in different lengths of the aorta at the greater and lesser curves of the arch.2  In hemiarch replacement surgery, using a single graft can result in kinks because of the right angle between the ascending aorta and the arch.2  We suggest using 2 separate grafts in hemiarch replacement, to facilitate the optimization of graft length and configuration when an appropriate method is used to identify the graft-to-graft anastomotic site. In total arch replacement, using more than one graft is a necessity. We propose that our method can be useful and easily applied in those patients who need 2 separate grafts.

References

References
1.
Ravichandran
PS
,
Floten
HS
,
Swanson
JS
,
Gately
HL
,
Hovaguimian
H
,
Furnary
AP
,
Starr
A.
Reversed bevel technique for anastomosis at the aortic arch
.
Ann Thorac Surg
1996
;
61
(
1
):
245
6
.
2.
Shiiya
N
,
Yasuda
K.
A new method for graft tailoring in hemiarch replacement
.
Ann Thorac Surg
2004
;
78
(
3
):
1105
6
.

Author notes

From: Department of Cardiovascular Surgery (Drs. Cagli, Diken, and Yalcinkaya), Hitit University, 19000 Corum; Department of Cardiovascular Surgery (Drs. Cagli and Lafci), Turkiye Yuksek Ihtisas Hospital, 06100 Ankara; and Department of Cardiovascular Surgery (Dr. Cagli), Numune Education and Research Hospital, 06100 Ankara; Turkey