ARTICLE IN PRESS
Interactive CardioVascular and Thoracic Surgery 8 (2009) 377–378
? 2009 Published by European Association for Cardio-Thoracic Surgery
Case report - Vascular thoracic
Single-stage repair of extended thoracic aortic aneurysm
Yuki Okamoto*, Masahiko Matsumoto, Hidenori Inoue
Second Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo City, Yamanashi, 409-3898, Japan
Received 13 August 2008; received in revised form 20 November 2008; accepted 24 November 2008
We report the case of a 78-year-old man with an extended thoracic aortic aneurysm in whom replacement of the ascending aorta, aortic
arch, and descending aorta were performed by single-stage repair. Single-stage repair surgical approach in this case was selected rather
than two-stage repair because of the risk of rupture of the aneurysm in the period before the second surgery and the patient’s somewhat
unstable mental condition that could have reduced his motivation for a second surgery. At surgery, replacement of descending aorta was
performed with thoracotomy in a right semisupine position, and replacement of ascending aorta and aortic arch was performed with a
median sternotomy in the supine position by changing the position of the left forearm. The postoperative course was smooth without major
complications. This case illustrates that the choice of surgical procedure should be made based on the shape of the aortic aneurysm and
the mental and general conditions of the patient.
? 2009 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.
Keywords: Extended thoracic aortic aneurysm; Single-stage repair
Thoracic aortic replacement for an aneurysm existing
simultaneously in the ascending aorta, aortic arch, and
descending aorta and for acute and chronic dissecting aortic
aneurysms can be performed as a single-stage or two-stage
repair. The strategy for extensive aortic replacement varies
depending on the patient’s condition and background, and
the diameter of aneurysm.
2. Case report
A 78-year-old man visited a previous physician with a chief
complaint of dorsal pain that appeared suddenly. A dilated
mediastinum was detected on a chest X-ray, and the patient
was admitted to our hospital for a thorough examination.
After admission, a chest X-ray showed a cardiothoracic
ratio of 53%, and the mediastinum and aortic arch were
dilated. Chest computed tomography (CT) indicated that
the ascending and descending aorta were dilated to a
maximum of 62 and 80 mm, respectively, but no dissection
or rupture was noted (Fig. 1). Transthoracic echocardio-
graphy showed no pericardial effusion, and the left ven-
tricular ejection fraction was 76.7%, indicating normal
systolic function. Mild aortic regurgitation was present.
Extended aneurysm of the thoracic aorta was diagnosed,
and surgery was scheduled.
The procedure in the left thoracic cavity was performed
with the patient in a right semisupine position, and a
midline incision was created by changing the position of
*Corresponding author. Tel.: q81 55 273 1111; fax: q81 55 273 6767.
E-mail address: firstname.lastname@example.org (Y. Okamoto).
the left forearm (Fig. 2). First, the thorax was opened at
the left 5th intercostal site. The descending aorta was
dilated to a maximum of 80 mm, but anastomosis of the
peripheral side in the region protruding into the right
thorax was considered possible, and taping of the descend-
ing aorta was applied. The left forearm position was
changed and the heart was approached by a median ster-
notomy in the supine position. Extracorporeal circulation
was initiated with blood withdrawn from the right atrium
and returned to the ascending aorta. Cooling was initiated,
ventricular fibrillation was induced, and a vent was inserted
into the right superior pulmonary vein. When the rectal
temperature decreased to 26.1 8C, the aorta was clamped,
and cardioplegic solution was infused to induce cardiac
arrest. The circulation was then arrested and the ascending
aorta was opened. The incision line was extended to the
arch. Antegrade selective cerebral perfusion was performed
at the same time. The posture was changed to the right
semisupine position and the procedure was continued via
the left thorax. Since the peripheral side of the descending
aorta was slightly vulnerable, the outer circumference was
strengthened with Teflon felt, and the graft with four
branches was used for anastomosis. The posture was then
changed to the supine position and perfusion of the lower
half of the body was started via the side branch of the
graft. The ascending aorta was trimmed, the outer circum-
ference of the graft was strengthened with Teflon felt, and
the graft was anastomosed to the ascending aorta 1 cm
above the sinotubular junction. After central anastomosis,
the clamped aorta was released, and the cervical branch
was reconstructed under cardiac beating. The duration of
extracorporeal circulation was 200 min, the aorta was
ARTICLE IN PRESS
Y. Okamoto et al. / Interactive CardioVascular and Thoracic Surgery 8 (2009) 377–378
Fig. 1. Preoperative CT.
Fig. 2. Operative position. (a) Right semisupine position, (b) Supine position.
clamped for 76 min, and the duration of circulatory arrest
was 54 min.
The postoperative course was smooth without major com-
plications, but the patient still had clinical depression. He
sometimes rejected meals and medication, and had a
negative attitude toward activities and rehabilitation.
Based on his request, and after consultation with his family,
the patient was transferred to another hospital for rehabil-
itation. The patient is doing well and has had no cardiovas-
cular event after surgery.
The therapeutic strategy for extended and dissecting
aortic aneurysms varies depending on the pathology and
the patient’s background. For aortic aneurysms, some facil-
ities perform single-stage repair by bilateral thoracotomy
or via a transmediastinal approach by median sternotomy
because the aneurysm may rupture or the general condition
of the patient may deteriorate during the waiting period
before the second surgery w1–5x. Furthermore, repeated
surgery itself carries a risk, the cost also differs, and
favorable outcomes can be achieved with one-stage repair
w1–5x. We decided to perform one-stage repair based on
the risk of rupture during the period prior to the second
surgery, the difficulty in anastomosis with the native blood
vessel using the elephant trunk method and a stent graft,
and the patient’s somewhat unstable mental condition that
could have reduced his motivation for the second surgery.
Regarding the surgical procedure, Safi et al. examined
early outcomes of two-stage extended replacement by the
elephant trunk method, and found that the hospital mor-
tality rates after the first and second steps were 6.3% and
9.6%, respectively w6x. LeMaire et al. found the hospital
mortality rates after the first and second step were 12.0%
and 4.0%, respectively, and reported that 51.0% of patients
were able to reach the second step w7x. There are some
reported cases of one-stage extended surgery. The out-
comes in these cases are comparable to the early outcomes
of two-stage repair. Kouchoukous et al. and Doss et al.
suggested that bilateral thoracotomy is particularly useful
for repeated surgery in cases that have undergone a midline
incision, in which the great blood vessels are relatively
undamaged, and the visual field is favorable; however,
there is an increased probability of wound infection due to
decreased blood flow caused by cutting of the internal
thoracic artery, and possible pulmonary complications asso-
ciated with thoracotomy w1–3x. Furthermore, Beaver et al.
reported that lesions extending maximally to the diaphragm
can be approached by a midline incision alone w4x. We
approached the lesion by a midline incision and thoracot-
omy, similar to Hu et al. who performed procedures on the
midline and in the left thorax by changing the position of
the left armw2x. We selected this method because changing
the arm position is easy and allows a very good visual field
to be maintained, thus avoiding potential complications
due to bilateral thoracotomy.
w1x Kouchoukos NT, Mauney MC, Masetti P, Castner CF. Optimization of
aortic arch replacement with a one-stage approach. Ann Thorac Surg
w2x Hu XP, Chang Q, Zhu JM, Yu CT, Liu ZT, Sun LZ. One-stage total or
subtotal aortic replacement. Ann Thorac Surg 2006;82:542–547.
w3x Doss M, Woehleke T, Wood JP, Martens S, Greinecker GW, Moritz A. The
clamshell approach for the treatment of extensive thoracic aortic
disease. J Thorac Cardiovasc Surg 2003;126:814–817.
w4x Beaver TM, Martin TD. Single-stage transmediastinal replacement of
the ascending, arch, and descending thoracic aorta. Ann Thorac Surg
w5x Westaby S, Katsumata T. Proximal aortic perfusion for complex arch
and descending aortic disease. J Thorac Cardiovasc Surg 1998;115:162–
w6x Safi HJ, Miller CC 3rd, Estrera AL, Villa MA, Goodrick JS, Porat E,
Azizzadeh A. Optimization of aortic arch replacement: two-stage
approach. Ann Thorac Surg 2007;83:S815–S818.
w7x LeMaire SA, Carter SA, Coselli JS. The elephant trunk technique for
staged repair of complex aneurysms of the entire thoracic aorta. Ann
Thorac Surg 2006;81:1561–1569.