A modified prosthesis eversion technique for proximal anastomosis in ascending aorta replacement

Abstract

Background: One of the crucial aspects of ascending aorta replacement is to achieve hemostasis of the proximal anastomosis. This study aimed to describe a modified prosthesis eversion technique for proximal anastomosis in ascending aorta replacement and compare its operative outcomes with the conventional prosthesis eversion technique.

Methods: We conducted a retrospective analysis of all consecutive patients who had ascending aortic aneurysm and underwent ascending aorta replacement with the modified or conventional prosthesis eversion technique between January 2019 and December 2022 in our center.

Results: A total of 108 patients were included: 55 in the modified group and 53 in the conventional group. The durations of cardiopulmonary bypass, aortic cross-clamping and total operation in the conventional group were longer than those in the modified group. Furthermore, perioperative blood loss and the incidence of re-exploration for bleeding were significantly lower in the modified group. Accordingly, patients in the conventional group accepted more blood transfusion. The modified group had a shorter duration in intensive care unit (ICU) and hospital, and lower total hospitalization costs than those in the conventional group.

Conclusions: The modified prosthesis eversion technique is an effective alternative for proximal anastomosis in ascending aorta replacement, with less blood loss, shorter operation time, and lower rate of postoperative complications compared with the conventional technique.

Keywords: Prosthesis eversion; ascending aorta replacement; clinical outcomes; proximal anastomosis.

Figure 1

Modification of the vascular prosthesis in the modified prosthesis eversion technique. (A) The vascular prosthesis was everted about 6 mm on one end, served as proximal end, and (B) is the schematic diagram of this step. (C) Two small 6-mm-high strips were cut away from the other end of the same prosthesis, and (D) is the schematic diagram of this step.

Figure 2

Performance of the lower half of proximal anastomosis in the modified prosthesis eversion technique. (A) The everted end of vascular prosthesis was positioned inside the aortic root with an overlapping of approximately 5–6 mm with the aorta stump, and (B) is the schematic diagram of this step. (C) The first needle is passed from the outside to the inside about 2–3 mm above the STJ, and then passed from the inside to the outside at the level of the STJ, and (D) is the schematic diagram of this step. (E) The series of “I” shape suture lines were shown after completing the lower half of proximal anastomosis, and (F) is the schematic diagram of this step. STJ, sinotubular junction.

Figure 3

Performance of the upper half of proximal anastomosis in the modified prosthesis eversion technique. (A) The upper half of proximal anastomosis was made up of two perfect serial tandem coils, using the out-to-inside and returning-to-the-out technique about 4 mm above the STJ, and (B) is the schematic diagram of this step. (C) The outer view of the stitches on the front wall of the proximal anastomosis, and (D) is the schematic diagram of this step. STJ, sinotubular junction.

Figure 4

Outer view after the completion of the proximal and distal anastomosis in the modified prosthesis eversion technique. (A) The proximal end of the vascular graft was conventionally anastomosed to the distal ascending aorta. (B) Schematic diagram after the completion of the proximal and distal anastomosis.

Figure 5

Schematic diagram of the proximal anastomosis in the conventional prosthesis eversion technique. (A) Strips of graft were placed around the external and internal walls of the aortic stump to reinforce the aortic root. And, 5-0 Prolene sutures were applied to fix the external and internal strips of graft at the level of the STJ using the same suture method as the lower half anastomosis of the modified prosthesis eversion technique. (B) The introverted prosthesis was inserted into the residual stump of the aorta and the left ventricle through the aortic valve, and the free margin of the prosthesis was positioned at the level of the rim of the repaired aortic root. Then the vascular graft was sewn to the reconstructed aorta with a 5-0 Prolene suture using the same suture method as the upper half anastomosis of the modified prosthesis eversion technique. After completion of the suture, the vascular graft was extracted from the left ventricle by pulling on the line previously fixed on the distal end of the prosthesis. STJ, sinotubular junction.