Mini-access open arch repair

Abstract

Background: The use of minimally invasive approaches is scarce in open aortic arch repair because of its perceived high operative risk and technical difficulty.

Methods: This study enrolled 59 consecutive patients (aged 58.2±13.2 years) undergoing elective arch replacement either through upper hemi-sternotomy (n=58) or mini-thoracotomy (n=1) between 2015 and 2020. Of these, 44 underwent hemiarch replacement and 15 underwent total arch replacement. Moderate hypothermic circulatory arrest was used for all patients while antegrade cerebral perfusion was selectively used for total arch repair. For more efficient distal aortic anastomosis in limited spaces, inverted graft anastomosis was utilized whenever possible.

Results: Hemi-sternotomy involved upper sternal separation down to the second, third, and fourth intercostal spaces in 1 (1.7%), 30 (50.8%), and 27 (45.8%) patients, respectively. Concomitant cardiac procedures included root replacement in 19 patients (32.2%) and aortic valve replacement in 21 patients (35.6%). Circulatory arrest, cardiac ischemic, cardiopulmonary bypass, and total procedural times were 8.9±3.4, 91.1±31.1, 114.6±46.2, and 250.3±79.5 min, respectively for total arch repair, and 25.0±12.1, 72.3±16.6, 106.0±16.9, and 249.1±41.7 min, respectively for hemiarch repair. Conversion to full-sternotomy was required in 1 patient (1.7%) due to bleeding. There was one case of mortality (1.7%) attributable to low-cardiac output syndrome following hemiarch repair concomitantly with Bentall procedure. Major complications included requirement for mechanical support in 1 (1.7%), temporary neurologic deficit in 1 (1.7%), newly initiated dialysis in 3 (5.1%), and re-exploration due to bleeding in 2 (3.4%).

Conclusions: Mini-access open arch repair is technically feasible and achieved excellent early outcomes.

Keywords: Aortic arch surgery; minimally invasive; partial sternotomy.

Figure 1

Exposure of the surgical field for total arch replacement via partial sternotomy (down to the third intercostal space).

Figure 2

Inverted graft technique: (A) The graft is rolled onto itself in an inside-out fashion and inserted into the proximal descending thoracic aorta. Double layer sutures are placed along the graft in a back-and-forth manner with 3-0 prolene. (B) The invaginated graft is pulled out and ready for anastomosis with the remaining graft.

Figure 3

Total arch replacement was performed using the following techniques: (A) For relatively small distal aorta (i.e., graft size <28 mm), a straight graft was used to construct distal anastomosis using (B) an inverted grafting technique and (C) a separate trifurcate graft to reconstruct the arch vessels. In cases (D) larger 4-branch graft could be used (≥28 mm), (E) branched portions of the graft were (F) inverted into the distal graft lumen. (G) After distal anastomosis, (H) the inverted portion of the graft was pulled out, and then the arch vessels were subsequently revascularized (I).