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Mini-Bentall Procedure and Hemiarch Replacement: Open Distal Anastomosis

Tuesday, May 16, 2017

In this video, the fifth in a seven-part series, Tristan Yan demonstrates how to perform a distal aortic anastomosis.

  1. Circulatory arrest is initiated. Brain protection is achieved with unilateral antegrade cerebral perfusion delivered via the innominate artery. As soon as the systemic temperature reaches 25 degrees centigrade, attention is turned to the distal hemiarch replacement.
  2. The patient’s head is packed in ice and antegrade flow is stopped. The aortic cannula is clamped, the aortic cross clamp is removed, and the patient’s blood is drained into the reservoir.
  3. The mid to distal ascending aorta is resected completely, together with the cannulation site. The under-surface of the proximal aortic arch is beveled.
  4. The inside of the aortic arch and the origins of epi-aortic vessels are inspected for any evidence of atheroma.
  5. Selective antegrade cerebral perfusion is achieved by cannulating the innominate artery, with or without the left common carotid artery.
  6. The open distal anastomosis is performed using a separate Ante-Flo graft with a single side arm (Vascutek Ltd, Renfrewshire, Scotland). A continuous 3-0 running polypropylene suture is used, starting from the point furthest away from the operating surgeon. The posterior aortic wall should be completed first.
  7. A nerve hook is used to tighten the suture along the posterior wall. The anterior half of the anastomosis is completed by picking up the other end of the suture and sewing towards the operating surgeon.
  8. The distal anastomosis is reinforced with pledgeted 4-0 prolene sutures to ensure an absolute hemostasis.
  9. After completion of the open distal anastomosis, antegrade systemic perfusion is resumed via the side-arm perfusion limb of the Ante-Flo graft.
  10. The patient is re-warmed towards 37 degrees centigrade.

Comments

Great technique to use a second suture with Teflon Felt reinforcement in the lumen. Why single pledgets and no felt strip? What if the distal aortic wall is dissected? Do you use GRF glue or any other fixation?
Thank you for your comment. I think it is easier to tell where the bleeding point is, if we use individual pledgets instead of felt strips. I often use Teflon felt strips for dissected aorta, but it all depends on the tissue strength and quality. I don't use bio-glue though.

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