https://orcid.org/0000-0002-9508-4088
Abstract
In the current endovascular era, open surgery through left posterolateral thoracotomy with moderate to deep hypothermic circulatory arrest remains an alternative for treating chronic distal arch or proximal descending aortic diseases, allowing cardiovascular surgeons to definitively repair the aorta in a single stage. When utilizing this approach, this report illustrates an alternative surgical technique for antegrade body perfusion during cooling, antegrade selective cerebral perfusion and rewarming, through a prosthetic graft on the right subclavian artery. This report shows the safety and feasibility of this technique during open distal arch and/or proximal descending aortic surgery through left posterolateral thoracotomy, after shifting the patient from a supine to the right lateral decubitus position.
INTRODUCTION
In the current endovascular era, open surgery through left posterolateral thoracotomy (PLT) with moderate to deep hypothermic circulatory arrest remains an alternative for treating chronic distal arch or proximal descending aortic diseases in case of unsuitable arch anatomy for safe thoracic endovascular aortic repair (TEVAR), connective tissue disease, small access vessels, young patients or after endovascular failure [1, 2]. Different than distal arch operations through median sternotomy, now commonly performed with frozen elephant trunk [3], which usually necessitates additional surgical or endovascular steps, this approach permits to definitively repair the aorta in a single stage. We illustrate a technique for antegrade perfusion during cooling, antegrade selective cerebral perfusion (ASCP) and rewarming through the right subclavian artery (RSA) [4] with this approach.
PROCEDURE
In supine position, the RSA is exposed through axillary incision and a prosthetic graft (10 mm diameter) to the RSA is anastomosed end-to-side for antegrade arterial perfusion of extracorporeal circulation (ECC). The left femoral artery and vein may be exposed for ECC at this stage, or after the patient is shifted to the right lateral decubitus position (Fig. 1). The exposed surgical area(s) are then covered in a sterile way before the patient’s position is shifted. Next, left PLT in the fourth intercostal space is performed and the distal arch, proximal descending aorta and supra-aortic vessels are exposed. In case of more distal aortic disease extension, a second thoracotomy in the seventh–eighth intercostal space is performed. After systemic heparinization, ECC is established using the prosthetic graft on the RSA, left femoral vein cannulation and vent in the left inferior pulmonary vein (Supplementary Material, Figs S1–S5). At the intended moderate or deep hypothermia (26–18°), the innominate artery (IA), left common carotid artery (LCCA) and left subclavian artery (LSA) are clamped and ASCP through the RSA at 5–10 ml/kg/min is initiated. Then, the middle-third of the descending aorta is clamped and retrograde visceral perfusion through the left femoral arterial cannula is started (Supplementary Material, Fig. S6).
Patient in supine position with right axillary access and prosthetic graft on the RSA for antegrade body perfusion and ASCP with left groin incision for femoral ECC access. ASCP: antegrade selective cerebral perfusion; ECC: extracorporeal circulation; RSA: right subclavian artery.
After proximal aortotomy (Fig. 2), the arch is inspected and cardioplegia administered using a Foley catheter after endo-occlusion of the aortic lumen. Next, proximal anastomosis is performed at the intentional level, usually represented by zones 2 and 3. Then, the aortic graft is clamped distal to the LSA and rewarming is initiated, declamping the supra-aortic vessels. Distal anastomosis and following surgical steps are performed in routine fashion (Supplementary Material, Figs S7 and S8).
Aortotomy of the distal arch and proximal descending aorta from left PLT with RSA ASCP and clamping of the supra-aortic vessels and middle-third of the descending aorta. PLT: posterolateral thoracotomy; RSA: right subclavian artery; ASCP: antegrade selective cerebral perfusion.
All surgical steps for performing this technique have been added to the Supplementary Material as a schematic list (Supplementary Material, Appendix A).
DISCUSSION
In patients with chronic aortic disease involving the distal arch and/or proximal descending aorta, managed with open surgery through left PLT, adoption of antegrade arterial perfusion during cooling, ASCP and rewarming can be similarly performed as for patients treated through median sternotomy. Although in this specific setting there is a necessity to shift the patient from a supine to right lateral decubitus position, this is relatively straightforward and safe if an adequate RSA graft clamping is performed, and sterile coverage of the axillary and, eventually the femoral area, is achieved.
Through a left PLT access, the supra-aortic vessels can be isolated for clamping to institute ASCP through the RSA alone, after preoperative confirmation of an intact circle of Willis which is routinely assessed with a computed tomography angiography of the cerebral arteries. We do not routinely use intracranial pressure monitoring. Although a cautious approach is recommended, such strategy prevents the presence of additional catheters for ASCP through the IA and LCCA in the surgical field which may challenge the proximal graft anastomosis. Additionally, the risk of air embolization may be lowered by avoiding direct instrumentalization and manipulation of the IA and LCCA. Similarly, cardiac protection with cardioplegia can be safely administered with a Foley catheter [2] in patients without aortic valve insufficiency and after endo-occlusion of the aortic lumen, which is regularly assessed during preoperative evaluations.
Adopting this approach, we have currently treated 3 patients affected by type IA endoleak after TEVAR (n = 2; 59, 52 years) and a severely tortuous and aneurysmatic distal arch and proximal descending aorta (maximum diameters of 78 mm × 73 mm) with a type B aortic dissection stretching from the proximal descending aorta to the infrarenal aorta and aneurysmatic widening of the origin of the LSA (n = 1; 49 years). This latter patient-specific aortic anatomy is reflected in all figures. All 3 patients did not have any neurological complication after surgery and were regularly discharged.
CONCLUSIONS
This report illustrates the safety and feasibility of antegrade body perfusion, ASCP and rewarming through a prosthetic graft on the RSA during open distal arch and/or proximal descending aortic surgery through left PLT.
SUPPLEMENTARY MATERIAL
Supplementary material is available at EJCTS online.
ACKNOWLEDGEMENTS
The authors are grateful to Fabio M. Calliari MD for providing the patient-specific illustrations.
Conflict of interest: none declared.
DATA AVAILABILITY
All relevant data are within the manuscript and in its online supplementary material.
ETHICAL STATEMENT
The patient provided informed consent for the publication of this technique and related imaging.
Reviewer information
European Journal of Cardio-Thoracic Surgery thanks Luca Di Marco and the other anonymous reviewer for their contribution to the peer review process of this article.
