von Segesser, Ludwig K.

RERO DOC Digital Library

Operative anatomy of the archLudwig K. von Segesser*Department of Surgery, CHUV, Lausanne, Switzerland* Corresponding author. Department of Surgery, CHUV, Rue du Bugnon 46, CH-1011 Lausanne, Switzerland. Tel: +41-21-3142279;e-mail: lk@segesser.com (L.K. von Segesser).Received 25 March 2012; accepted 1 April 2012Keywords: Thoracic aorta • Aortic arch • Aneurysm • Repair • AnatomyOPERATIVE ANATOMY OF THE ARCHAneurysmal disease of the aorta carries the risk of an ongoingprogression in the long term, and, thus, it comes as no surprisethat the number of publications dealing with extended aorticaneurysm repair is increasing. In 2011, there have been, in theEuropean Journal of Cardio-Thoracic Surgery alone, numerousreports on aortic aneurysm repair, including, among others theascending aorta and root [1–4], the descending thoracic andthoraco-abdominal aorta [5–8], the arch in-between [9–12] andalso more general issues [13–18].Ascending aortic aneurysm repair is familiar to most cardiacsurgeons from the aortic root to the proximal part of the aorticarch and the same holds true for the descending thoracic aorta,be it with or without the distal aortic arch. However, if the aorticarch is also diseased in between the proximal and the distal part,usually requiring total arch repair in addition to ascending anddescending aortic cures, the battleﬁeld may be somewhat less fa-miliar to many of us.In this issue, Hino et al. [19] report their experience with theextended replacement of the thoracic aorta, including a con-secutive series of 29 patients with total arch replacement; out ofwhom about half had already undergone Bentall de Bonoprocedures, TEVAR and/or hemi-arch repair previously. This isindeed a complex group of patients. The preferred surgicalapproach of Hino et al. was a left postero-lateral thoracotomywith femoro-femoral cardiopulmonary bypass using additionalvenous drainage in six of 29 patients versus other drainage sitesin 13 of 29 patients (right atrium and pulmonary artery) andadditional arterial inﬂow in seven of 29 versus other sites inseven of 29 in moderate-to-deep hypothermia. Brain protectionwas realized with antegrade cerebral perfusion using balloon-tipped catheters from the inside of the aortic arch. The outcomein the series was outstanding with a 30-day mortality of two of29 patients and a 5-year actuarial survival of 80.6 + 9.0% andfreedom from subsequent aortic events of 96.0 + 3.9%. Only onepatient suffered from reversible right forearm paralysis and onepatient suffered from transient paraparesis. The authors do notreport any transient or permanent brain nerve lesions althoughseveral, i.e. n. vagus, n. recurrens and n. phrenicus, are withinthe surgical ﬁeld at various levels. Considering hard endpoints,like mortality and stroke, this aspect may seem to be a minorissue and, therefore, appears to be somewhat underreported inthe current literature. Symptoms of laryngeal nerve fatigue eitherdue to an overstretched recurrent nerve or a transsected oneFigure 1: Operative anatomy of the arch seen from the left side with its inter-woven noble structures which are to be preserved: courtesy of Berdajs andTurina [20].© The Author 2012. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.EDITORIALSEuropean Journal of Cardio-Thoracic Surgery 42 (2012) 201–202 EDITORIALdoi:10.1093/ejcts/ezs262can be handled quite well, by the injection of (re-absorbable ornot) deposits for the medialization of the respective vocal cords;however, this is less the case for two. Postoperative problemscan also be expected if one or both phrenic nerves are touchedseverely enough to require a breathing pacemaker and/or otheradjuncts.As a matter of fact, the aortic arch and its branches are stillfairly simple structures from the inside, where there are threemain oriﬁces of the supra-aortic vessels and there are variationsto be identiﬁed and reconnected. However, the outside of theaortic arch within the mediastinum and, more cranially, its efﬂu-ents are in somewhat lesser known territory, where severalnoble structures are crossing that deserve to be identiﬁed andpreserved whenever possible. It was recognized a long time agothat thorough knowledge of the anatomy and its variations is keyto success in surgery. Fortunately, major efforts have been madein the past to study the surgical anatomy. Figure 1 displays theaortic arch seen from the left side. Its relationship with thenerves and other noble structures close by are just one exampleof the interwoven structures of the human body, where noempty space exists. More about the operative anatomy of thearch and how to get there can be found in a recent publicationby Berdajs and Turina [20] with the self-descriptive title ‘OperativeAnatomy of the Heart’. This masterpiece with >1000 illustrationsdeserves to be visited prior to the next operative journey intoknown and less well-known territories.Conﬂict of interest: none declared.REFERENCES[1] Jackson V, Petrini J, Caidahl K, Eriksson MJ, Liska J, Eriksson P et al.Bicuspid aortic valve leaﬂet morphology in relation to aortic rootmorphology: a study of 300 patients undergoing open-heart surgery. EurJ Cardiothorac Surg 2011;40:e118–24.[2] Bernhardt AMJ, Treede H, Rybczynski M, Sheikzadeh S, Kersten JF,Meinertz T et al. Comparison of aortic root replacement in patients withMarfan syndrome. Eur J Cardiothorac Surg 2011;40:1052–7.[3] Guo H-W, Sun X-G, Xu J-P, Xiong H, Wang X-Q, Su W-J et al. A new andsimple classiﬁcation for the non-coronary sinus of Valsalva aneurysm.Eur J Cardiothorac Surg 2011;40:1047–51.[4] Blehm A, Smiris K, Schurr P, Lichtenberg A. Transapical aortic valve im-plantation after ascending aortic endovascular repair. Eur J CardiothoracSurg 2012;41:1206.[5] Czerny M, Hoebartner M, Sodeck G, Funovics M, Juraszek A, Dziodzio Tet al. The inﬂuence of gender on mortality in patients after thoracicendovascular aortic repair. Eur J Cardiothorac Surg 2011;40:e1–5.[6] Narayan R, Wong A, Davies I, Angelini GD, Bryan AJ, Wilde P et al.Thoracic endovascular repair versus open surgical repair—which is themore cost-effective intervention for descending thoracic aortic patholo-gies? Eur J Cardiothorac Surg 2011;40:869–74.[7] Weigang E, Parker JATC, Czerny M, Lonn L, Bonser RS, Carrel TP et al.Should intentional endovascular stent-graft coverage of the left sub-clavian artery be preceded by prophylactic revascularisation? Eur JCardiothorac Surg 2011;40:858–68.[8] Weiss G, Wolner I, Folkmann S, Sodeck G, Schmidli J, Grabenwöger Met al. The location of the primary entry tear in acute type B aortic dissec-tion affects early outcome. Eur J Cardiothorac Surg doi:10.1093/ejcts/ezs056.[9] Glauber M, Murzi M, Farneti P, Bevilacqua S, Mariani M, Tognarelli Aet al. Aortic arch replacement with prophylactic aortic arch debranchingduring type A acute aortic dissection repair: initial experience with 23patients. Eur J Cardiothorac Surg 2011;40:418–23.[10] Kim JB, Chung CH, Moon DH, Ha GJ, Lee TY, Jung SH et al. Total archrepair versus hemiarch repair in the management of acute DeBakeytype I aortic dissection. Eur J Cardiothorac Surg 2011;40:881–9.[11] Ius F, Hagl C, Haverich A, Pichlmaier M. Elephant trunk procedure 27years after Borst: what remains and what is new? Eur J Cardiothorac Surg2011;40:1–12.[12] Di Eusanio M, Armaro A, Di Marco L, Pacini D, Savini C, Suarez SM et al.Short- and midterm results after hybrid treatment of chronic aortic dis-section with the frozen elephant trunk technique. Eur J CardiothoracSurg 2011;40:875–80.[13] Khaladj N, Peterss S, Pichlmaier M, Shrestha M, von Wasielewski R, HoyL et al. The impact of deep and moderate body temperatures onend-organ function during hypothermic circulatory arrest. Eur JCardiothorac Surg 2011;40:1492–500.[14] Biancari F, Vasques F, Benenati V, Juvonen T. Contemporary results aftersurgical repair of type A aortic dissection in patients aged 80 years andolder: a systematic review and meta-analysis. Eur J Cardiothorac Surg2011;40:1058–63.[15] Zhang L, Liao M-F, Tian L, Zou S-L, Lu Q-S, Bao J-M et al.Overexpression of interleukin-1β and interferon-γ in type I thoracicaortic dissections and ascending thoracic aortic aneurysms: possible cor-relation with matrix metalloproteinase-9 expression and apoptosis ofaortic media cells. Eur J Cardiothorac Surg 2011;40:17–22.[16] Parietti E, Pallandre J-R, Deschaseaux F, Aupècle B, Durst C, Kantelip J-Pet al. Presence of circulating endothelial progenitor cells and levels ofstromal-derived factor-1α are associated with ascending aorta aneurysmsize. Eur J Cardiothorac Surg 2011;40:e6–12.[17] Thalmann M, Sodeck GH, Domanovits H, Grassberger M, Loewe C,Grimm M et al. Acute type A aortic dissection and pregnancy: apopulation-based study. Eur J Cardiothorac Surg 2011;39:e159–63.[18] Rylski B, Suedkamp M, Beyersdorf F, Nitsch B, Hoffmann I, Blettner Met al. Outcome after surgery for acute aortic dissection type A in patientsover 70 years: data analysis from the German Registry for Acute AorticDissection Type A (GERAADA). Eur J Cardiothorac Surg 2011;40:435–40.[19] Hino Y, Okada K, Oka T, Inoue T, Tanakal A, Omura A et al. Extended re-placement of the thoracic aorta. Eur J Cardio-Thorac Surg 2012doi:10.1093/ejcts/ezs200.[20] Berdajs D, Turina MI. Operative Anatomy of the Heart. Berlin: Springer,2011.L.K. von Segesser / European Journal of Cardio-Thoracic Surgery202

Operative anatomy of the arch

Abstract

Similar works

Full text

Available Versions

RERO DOC Digital Library