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J Thorac Cardiovasc Surg 1999;118:208-209
© 1999 Mosby, Inc.

LETTERS TO THE EDITOR

Arch-first technique through left antero-axillary thoracotomy or bilateral anterior thoracotomy

Missouri Baptist Medical Center
Cardiac, Thoracic & Vascular Surgery Inc
3009 North Ballas Rd, Suite 266 C
St Louis, MO 63131

Reply to the Editor:

We appreciate the comments of Sasaguri and Fukuda. We did not claim in our publication that the techniques we used were original. In fact, we referred to previous use of the bilateral thoracotomy approach, ^1-3 early antegrade cerebral perfusion to minimize the period of circulatory arrest, ⁴ as well as total replacement of the thoracic aorta in a single stage. ^2,3 We incorporated these techniques into a procedure that was used in patients who required extensive thoracic aortic resections, as well as aortic valve or root replacement and coronary artery bypass grafting.

We are familiar with the reports of Sasaguri and his colleagues ^5,6 on the use of the left antero-axillary thoracotomy for aortic arch reconstruction. In their 1997 publication, ⁶ they described and illustrated perfusion of the aortic arch after attachment of separate grafts to the 3 brachiocephalic arteries and to the aortic graft, but before completion of the proximal and distal aortic anastomoses. Our technique uses a single anastomosis to a cuff of aorta surrounding the brachiocephalic arteries to minimize the duration of brain ischemia. They also indicated that disease requiring resection of the aorta below the level of the eighth thoracic vertebra should be approached through a posterolateral thoracotomy. ^5,6

In our series, which now includes 13 patients with 1 hospital death and no late deaths, the distal anastomosis of the aortic graft to the thoracic aorta was performed at or below the junction of the middle and distal thirds of the descending thoracic aorta in 7 patients. In addition, 7 patients required aortic valve or aortic root replacement or repair, and 6 required coronary artery bypass grafting (5 to the right coronary system). Eight patients had previous operations for acute ascending aortic dissection, and the ascending aorta was enlarged or adherent to the sternum in all. It is highly improbable, in our opinion, that these extensive procedures could have been adequately or safely accomplished through an antero-axillary thoracotomy. We fully agree with Sasaguri and Fukuda that the bilateral anterior thoracotomy is more invasive than a left antero-axillary thoracotomy. However, we believe that operations in patients with aortic disease that is not confined to the distal aortic arch and the proximal descending thoracic aorta, particularly those with chronic type A dissections who have had previous operations on the ascending aorta, will require a more extensive approach for optimal treatment.

12/8/98434

References

1. Cooley D. Surgical treatment of aortic aneurysms. Philadelphia: Saunders; 1986. p. 58-9.
   
2. Massimo CG, Presenti LF, Marranci P, et al. Extended and total aortic resection in the surgical treatment of acute type A aortic dissection: experience with 54 patients. Ann Thorac Surg 1988;46:420-4.[Abstract]
   
3. Minale C, Splittgerber FH, Reifschneider HJ. Replacement of the entire thoracic aorta in a single stage. Ann Thorac Surg 1994;57:850-5.[Abstract]
   
4. Ergin MA, Griepp EB, Lansman SL, Galla JD, Levy M, Griepp RB. Hypothermic circulatory arrest and other methods of cerebral protection during operations on the thoracic aorta. J Card Surg 1994;9:525-37. [Medline]
   
5. Sasaguri S, Yamamoto S, Fukuda T, Hosoda Y. Anteroaxillary thoracotomy facilitates the use of retrograde cerebral perfusion in distal aortic arch reconstruction. Ann Thorac Surg 1996;62:1861-2.[Abstract/Free Full Text]
   
6. Sasaguri S, Yamamoto S, Fukuda T, Hosoda Y. Retrograde cerebral perfusion through antero-axillary thoracotomy in the aortic arch surgery. Eur J Cardiothorac Surg 1997;11:657-60.[Abstract]
   

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Nicholas T. Kouchoukos Chris K. Rokkas Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Kouchoukos, N. T. Articles by Rokkas, C. K. Search for Related Content PubMed Articles by Kouchoukos, N. T. Articles by Rokkas, C. K.