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Total videoscopic bypass graft implantation on the ascending aorta for lower limb revascularization

2005; Elsevier BV; Volume: 42; Issue: 2 Linguagem: Inglês

10.1016/j.jvs.2005.03.064

1097-6809

Isabelle Javerliat, Marc Coggia, Isabelle Di Centa, Pascal Alfonsi, Giovanni Colacchio, Michel Kitzis, Olivier Goëau-Brissonnière,

Cardiac and Coronary Surgery Techniques

An extra-anatomic bypass initiating from the ascending aorta, namely the ventral aorta, is a possible alternative for lower limb revascularization. However, acceptance of this technique is limited by the need of a median sternotomy and clamping of the ascending aorta. We report a new technique for the ventral aorta using a total videoscopic approach of the ascending aorta, which avoids the need for a median sternotomy. We discuss the advantages and perspectives of this new approach. An extra-anatomic bypass initiating from the ascending aorta, namely the ventral aorta, is a possible alternative for lower limb revascularization. However, acceptance of this technique is limited by the need of a median sternotomy and clamping of the ascending aorta. We report a new technique for the ventral aorta using a total videoscopic approach of the ascending aorta, which avoids the need for a median sternotomy. We discuss the advantages and perspectives of this new approach. An extra-anatomic bypass graft originating from the ascending aorta is an alternative for lower limb revascularization when the abdominal and descending thoracic aorta are either unusable or unsuitable for proximal graft implantation.1Baird R.J. Madras P.N. Ascending aorta to bilateral femoral artery graft via a ventral subcutaneous route.Ann Surg. 1977; 186: 210-212Crossref PubMed Scopus (15) Google Scholar, 2Favi P. Massimo C. Diligenti L.M. Ascending aorta to femoral arteries bypass without opening the abdominal cavity. Choice treatment in cases of complete occlusion of the infrarenal aorta.J Cardiovasc Surg. 1977; 18: 475-480PubMed Google Scholar We report a new technique for bypass grafting from the ascending aorta that avoids the need for median sternotomy and could provide an important decrease in surgical trauma. This technique could also be used for other types of bypass grafts implanted on the ascending aorta. The patient is placed in the supine position, and the right side is elevated to 20° to 30° with an inflatable pillow (Pelvic-Tilt, O.R. Comfort, LLC, Glen Ridge, NJ) (Fig 1). A conventional approach of the intra-abdominal vessels or femoral arteries is first performed. A one-lung ventilation technique is used during the videoscopic step. The videoscopic approach of the ascending aorta is performed with the operator standing on the right side of the patient. The assistant-camera is on the right of the operating surgeon. A 45° endoscope (Storz-France SA, Paris, France) is positioned through a 10-mm port (Storz-France SA) introduced in the second right intercostal space, 3 cm laterally from the sternum. Fig 1 shows the sites where the ports are inserted. The chest cavity is insufflated up to 7 mm Hg. The pericardium is dissected anteriorly and cranially until the innominate vein. The upper third of the pericardium is opened, exposing ascending aorta (Fig 2, A). A stitch is placed on the inferior border of the pericardium and pulled out through the right chest wall. The tunnel between the chest cavity and peripheral vessels depends on type of bypass. A preperitoneal tunnel to the right groin is performed with the use of short subcostal and paraumbilical incisions (case 1). A tunnel to the intra-abdominal vessels is performed through the central tendon of the diaphragm and behind the left side of the liver (case 2). The vascular prosthesis (Gelsoft Plus or Gelweave, Vascutek-Terumo, Inchinnan, Scotland) is beveled to allow an end-to-side anastomosis. It is introduced in the chest through one of the ports. An aortic clamp is introduced from the subcostal incision or from the abdomen, and its tip is conducted in the chest cavity under videoscopic control. The prosthesis is then easily brought to the right groin or to the abdomen. Before clamping, running sutures are prepared as previously described. A side-biting De Bakey clamp (Pilling, Bourbon l’Archambault, France) is introduced percutaneously through the fourth right parasternal intercostal space. Before clamping, the arterial systolic pressure is regulated to <100 mm Hg. The right side of the ascending aorta is clamped (Fig 2, B). Clamping efficacy can be checked with a needle introduced through a port. The aortotomy is performed with laparoscopic knife and angulated Potts scissors. The end-to-side anastomosis is begun at the heel with a single stitch and then completed with two hemicircumferential running sutures previously knotted on pledgets and tied together intracorporally (Fig 2, C).3Coggia M. Bourriez A. Javerliat I. Goëau-Brissonnière O. Totally laparoscopic aortobifemoral bypass a new and simplified approach.Eur J Vasc Endovasc Surg. 2002; 24: 274-275Abstract Full Text PDF PubMed Scopus (90) Google Scholar Before unclamping, air bubbles are removed with a needle. Hemostasis of the anastomosis is checked after arterial pressure normalization (Fig 2, D). The pericardium is left open, with fat interposition between the lung and the prosthesis. The pneumothorax is deflated, two chest tubes are placed, and the ports are removed under videoscopic control. After positioning of the prosthesis, conventional peripheral anastomoses are performed. A 72-year-old man presented critical ischemia in the left limb. Two years ago, he underwent a long, right iliac stenting with a crossover femorofemoral bypass. In 1983, he underwent a total cystectomy with a right nephrectomy and pelvic radiotherapy (65 Gy). In 2003, he underwent a cholecystectomy and an abdominoperineal amputation for rectal cancer with a left iliac colostomy. Angiography demonstrated occlusion of the crossover bypass, with long, right iliac intrastent restenosis. The patient was scheduled for an aortobifemoral bypass. The abdominal aorta was considered unusable because of previous abdominal surgery and radiotherapy. The descending thoracic aorta was considered unusable because of potential difficulties for tunnelling between the chest cavity and the groins as well as a past history of recurrent left pneumopathy. An axillobifemoral bypass could have been performed, but considering the patient’s good surgical risk, he was scheduled for a videoscopic ascending aorta-to-bifemoral artery bypass, for which he gave an informed consent. His preoperative assessment showed normal cardiac and pulmonary test results. The surgical procedure was performed according to the technique described. A preperitoneal tunneling of the graft between the ascending aorta and the right groin was scheduled because of previous abdominal surgery. Total operative time was 310 minutes. Clamping time of the ascending aorta was 45 minutes. Total blood loss from the procedure was 580 mL. His postoperative course was uneventful. The hospital stay was 11 days. A control computed tomography (CT) scan showed a patent tube graft without morphologic anomalies (Fig 3, A and B). The patient did well at the 6-month follow-up, without morphologic and hemodynamic anomalies on duplex study. A 72-year-old man presented with bilateral, painful, blue toe syndrome. His risk factors included diabetes mellitus, cigarette smoking, and uncontrolled hypertension. Two months before, he presented with acute pancreatitis. He also had a renal insufficiency (34.1 mg/L). Diagnosis of atheroembolization was made on the basis of these characteristic clinical findings.4Hollier L.H. Kazmier F.J. Ochsner J.L. Bowen J. Procter C.D. Shaggy aorta syndrome with atheromatous embolization to visceral vessels.Ann Vasc Surg. 1991; 5: 439-444Abstract Full Text PDF PubMed Scopus (74) Google Scholar A CT scan showed a shaggy aorta, including the thoracic and abdominal aortas. The patient was scheduled for an extra-anatomic revascularization of the lower limbs and abdominal trunks rather than for a direct thoracic replacement. He was then scheduled for a videoscopic ascending aorta-to-visceral and lower limbs revascularization. The surgical procedure was performed according to the technique described. Total operative time was 460 minutes. Clamping time of the ascending aorta was 50 minutes. Total blood loss from the procedure was 1,860 mL. His postoperative course was complicated by a prolonged ileus, probably due to the laparotomy needed for visceral revascularization, and he returned to a general diet at day 15. A postoperative CT scan showed patent grafts without morphologic abnormalities. The hospital stay was 21 days. The patient did well at the 2-month follow-up. Bypass grafting from the ascending aorta for lower limbs revascularization did not gain widespread acceptance because of substantial morbidity caused by the median sternotomy and need for clamping of the ascending aorta. Moreover, a less-invasive axillofemoral bypass is often feasible. However, in young and good surgical-risk patients, the drawback of an axillofemoral bypass for critical limb ischemia is a low patency rate.5Kaufman J.L. Saifi J. Chang B.B. Shah D.M. Leather R.P. The role of extraanatomic exclusion bypass in the treatment of disseminated atheroembolism syndrome.Ann Vasc Surg. 1990; 4: 260-263Abstract Full Text PDF PubMed Scopus (7) Google Scholar On the other hand, the patency rate reported with ascending aorta-to-femoral arteries bypass is about 70% at 5 years.6Baird R.J. Ropchan G.V. Oates T.K. Weisel R.D. Provan J.L. Ascending aorta to bifemoral bypass-a ventral aorta.J Vasc Surg. 1986; 3: 405-410Abstract Full Text PDF PubMed Scopus (17) Google Scholar The conventional surgical approach of the ascending aorta for bypass grafting is usually performed through a full or upper midline sternotomy.1Baird R.J. Madras P.N. Ascending aorta to bilateral femoral artery graft via a ventral subcutaneous route.Ann Surg. 1977; 186: 210-212Crossref PubMed Scopus (15) Google Scholar, 2Favi P. Massimo C. Diligenti L.M. Ascending aorta to femoral arteries bypass without opening the abdominal cavity. Choice treatment in cases of complete occlusion of the infrarenal aorta.J Cardiovasc Surg. 1977; 18: 475-480PubMed Google Scholar, 6Baird R.J. Ropchan G.V. Oates T.K. Weisel R.D. Provan J.L. Ascending aorta to bifemoral bypass-a ventral aorta.J Vasc Surg. 1986; 3: 405-410Abstract Full Text PDF PubMed Scopus (17) Google Scholar, 7Sakopoulos G.A. Ballard J.L. Gundry S.R. Minimally invasive approach for aortic arch branch vessel reconstruction.J Vasc Surg. 2000; 31: 200-202Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar The potential advantage of videoscopy is to provide a simple, anatomic approach of the ascending aorta, thus avoiding the complications of sternal splitting, especially pain and wound complications.8Dalton M.L. Connally S.R. Median sternotomy.Surg Gyn Obstet. 1993; 176: 615-624PubMed Google Scholar As demonstrated in Fig 3 (B), videoscopy allows an exposure of the ascending aorta on its right side, which is important for graft implantation. With our technique, placing the patient in the dorsal decubitus position simplifies anaesthetic management, and the patient is already positioned for a sternotomy if difficulties arise during dissection or anastomosis. A drawback of our videoscopic approach is the reduced working space behind the sternum. We used a carbon dioxide pneumothorax, which provided a larger working space without mediastinal compression or hemodynamic consequences. Higher pneumothorax pressure is probably possible, as we did for the videoscopic treatment of a thoracoabdominal aneurysm.9Coggia M. Javerliat I. Di Centa I. Royer B. Kitzis M. Goëau-Brissonnière O. Total videoscopic treatment of a type IV thoraco-abdominal aneurysm.J Vasc Surg. 2005; 41: 141-145Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar The main challenge of videoscopy is the performance of side-biting clamping of the ascending aorta. Because of the close nature of the approach, catastrophic complications could manifest with clamp failure. In our cases, side-biting clamping of the ascending aorta was performed with a De Bakey clamp designed for open surgery. Videoscopic secured side-biting clamps are in development, however. It is also essential to perform a preoperative CT scan to assess topography and the extent of calcification of the ascending aorta because the main drawback of videoscopy is the lack of sensory feedback before clamping. We believe that extensive calcification of the ascending aorta is a contraindication for a videoscopic bypass. This new and relatively simple technique seems promising and could also be used for other types of bypasses implanted on the ascending aorta, especially bypass grafts for supra-aortic trunk revascularization10Kieffer E. Sabatier J. Koskas F. Bahnini A. Atherosclerotic innominate artery occlusive disease early and long-term results of surgical reconstruction.J Vasc Surg. 1995; 21: 326-337Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar, 11Berguer R. Morasch M.D. Kline R.A. Transthoracic repair of innominate and common carotid artery disease immediate and long-term outcome for 100 consecutive surgical reconstructions.J Vasc Surg. 1998; 27: 34-42Abstract Full Text Full Text PDF PubMed Scopus (127) Google Scholar and for the treatment of complex aortic lesions in which difficulties are anticipated with the anatomic repair.12Robicsek F. Hess P.J. Vajtai P. Ascending-distal abdominal aorta bypass for treatment of hypoplastic aortic arch and atypical coarctation in the adult.Ann Thorac Surg. 1984; 37: 261-263Abstract Full Text PDF PubMed Scopus (36) Google Scholar, 13Barron D.J. Lamb R.K. Ogilvie B.C. Monro J.L. Technique for extra-anatomic bypass in complex aortic coarctation.Ann Thorac Surg. 1996; 61: 241-244Abstract Full Text PDF PubMed Scopus (32) Google Scholar Its place in the armamentarium of vascular surgeons to treat aortoiliac occlusive disease will depend on their skills in laparoscopic surgery.14Coggia M. Javerliat I. Di Centa I. Colacchio G. Leschi J.P. Kitzis M. et al.Total laparoscopic bypass for aortoiliac occlusive lesions 93-cases experience.J Vasc Surg. 2004; 40: 899-906Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar, 15Coggia M. Javerliat I. Di Centa I. Colacchio G. Cerceau P. Kitzis M. et al.Total laparoscopic infrarenal aortic aneurysm repair preliminary results.J Vasc Surg. 2004; 40: 448-454Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar In fact, we don’t think that any additional specific skills are necessary for a videoscopic graft implantation on the ascending aorta once basic laparoscopic aortic skills have been learned. So, for surgeons with such experience, we think it could be an interesting alternative for lower limb revascularization when an extra-anatomic bypass is mandatory in good surgical-risk patients.