What Suture To Use In Aorta Repair
Groundwork
Although the ultimate success of aortic operations depends upon the integrity of graft-to-aorta anastomoses, trivial is known about different techniques used to clinch their longevity. We report the incidence of reoperation for suture line disruptions arising from anastomoses using reinforcement with Teflon felt.
Methods
Since 1987, 1475 patients underwent 2281 anastomoses in the thoracic aorta (mean 1.55/anastomoses per patient). All patients were followed with at least yearly computed tomographic scans, for a total follow-upwards of 6483.8 patient-years. Those requiring reoperation were reviewed retrospectively for evidence of suture line disruption.
Results
Only 34 patients, with a mean historic period of 55.i years former (range 26–85 years old) underwent reoperation for suture-line disruptions following vascular graft-to-aorta anastomosis using Teflon felt. The previous operation was a Bentall procedure in 15 (44%); ascending aorta replacement in 9 (26%); total curvation replacement in 6 (xviii%); descending aorta replacement in 2 (6%); thoracoabdominal repair in 1 (3%); and sinus of Valsalva repair in 1 (3%). The incidence of suture line disruption was 0.0052 per patient-twelvemonth, and 0.0034 per anastomosis-twelvemonth. The mean interval between operations was 55.9 months (range 4–180 months). In 21%, the pseudoaneurysm originated from the proximal anastomosis; in 71% from the distal anastomosis; in 3% from both; in 3% from the innominate artery; and in iii% from a sinus of Valsalva repair. In just 1 patient was in that location show of infection. Reoperation involved ascending aorta replacement in eleven patients, and total arch replacement in 13 patients. Adverse upshot, such every bit hospital death or permanent stroke, occurred in 8% (3 patients).
Conclusions
Apply of Teflon felt to support aortic suture lines yields a very depression incidence of suture line disruptions: one per 191 patient-years, or one per 296 anastomosis-years. Teflon felt reinforcement provides a secure, long-lasting graft-to-aorta anastomosis with minimal risk of infection.
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Recent improvements in surgical and neuroprotective techniques, likewise equally in perioperative care, have resulted in a low hospital mortality and ameliorate long-term result for patients with aneurysmal disease of the thoracic aorta. Every bit a consequence, the number of patients at risk for development of late complications after reconstructive surgery on the thoracic aorta is increasing [
1
- Dossche K.M.
- Tan 1000.E.
- Schepens Yard.A.
- Morshuis W.J.
- de la Rivere A.B.
Twenty-four yr experience with reoperations after ascending or aortic root replacement.
- Crossref
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]. The routine use of echocardiography and computed tomography in the evaluation of patients after operations on the thoracic aorta has identified abnormalities in asymptomatic or minimally symptomatic patients that may require reoperation for a variety of indications [
,
]. Suture-line disruptions are among the belatedly complications that can cause substantial mortality and morbidity even years after primary repair of aortic lesions.
The incidence of imitation aneurysms or dissections originating from suture lines betwixt grafts and the aorta is low, merely we take seen a number over the by years, usually in patients in whom Teflon (DuPont Pharmaceuticals, Wilmington, DE) felt was non used to reinforce the suture line. Suture line disruption is a life-threatening complication afterwards thoracic aortic surgery, requiring reoperation in all cases. Even in hemodynamically stable situations in which the fake aneurysm does not appear to be expanding, there is no dubiousness that reoperation volition become necessary. But although the ultimate success of aortic operations depends upon the integrity of graft-to-aorta anastomoses, surprisingly little is known about the different surgical techniques used to assure their longevity. Some information is available for the occurrence of a simulated aneurysm subsequently surgical repair of astute aortic dissection: the incidence is said to exist ii% to iii% [
4
- Bachet J.E.
- Termignon J.L.
- Dreyfus One thousand.
- et al.
Aortic dissection-prevalence, cause and results of late reoperations.
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,
,
6
- Ergin M.A.
- Galla J.D.
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Hypothermic circulatory abort in operations on the thoracic aorta.
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, five, half-dozen].
The aim of this study was to define the incidence of late anastomotic disruptions occurring in suture lines reinforced with Teflon felt, and the result of patients in whom this complexity prompted reoperation.
Fabric and Methods
Patients
From June 1987 to July 2002, 1475 patients underwent operations involving the thoracic aorta. The median age was 64 years old (range 8 to 89 years erstwhile). For other clinical characteristics come across Tabular array one. Overall, these patients had 2281 anastomoses in the thoracic aorta, with a mean of 1.55 anastomoses per patient. All aortic anastomoses were reinforced with a strip of Teflon felt. All patients were followed with at least yearly compute tomographic (CT) scans, for a total follow-upwards of 6483.8 patient-years. Patients who died or were lost to follow-upwards were included merely until the appointment of the latest CT scan that showed intact suture lines. The follow-up analysis had the post-obit characteristics: 88 patients were lost to follow-up, later a mean interval of 4.6 ± 3.one years; 227 patients died during follow-upwardly, later a mean ii.7 ± 3.1 years. The hateful follow-up interval was six.2 years.
Table one Patient Characteristics (of 1475 Patients)
| Variable | Pct | Number of Patients |
|---|---|---|
| Etiology | ||
| Astute dissection | nineteen | 280 |
| Chronic dissection | 15 | 222 |
| Atherosclerotic/degenerative aneurysms | 48 | 708 |
| Anuloectatic aorta | 5 | 74 |
| Marfan syndrome | 7 | 103 |
| Others/miscellaneous | 6 | 88 |
| Type of repair during initial operation | ||
| Bentall/David/Yacoub | 47 | 698 |
| Ascending aortic replacement/proximal arch | 10 | 141 |
| Total arch | 12 | 183 |
| Descending aortic replacement | 11 | 157 |
| Thoracoabdominal aortic replacement | 5 | 79 |
| Others | 15 | 217 |
| Gender | ||
| Female | 33 | 487 |
| Male person | 67 | 988 |
| Age | ||
| > 60 years erstwhile | 57 | 849 |
| ≤ 60 years one-time | 43 | 626 |
| Preoperative hazard factors | ||
| Hypertension | 56 | 841 |
| Smoking | 44 | 634 |
| Coronary artery disease | 19 | 280 |
| Diabetes mellitus | 11 | 162 |
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Those requiring reoperation were reviewed retrospectively for evidence of suture line disruption.
Surgical Technique
All aortic anastomoses were performed using a standardized technique. Prolene (3-0) was used in the vast majority; a few patients had anastomosis performed with 4-0 Prolene. The back wall of the anastomosis was carried out open, with a continuous suture passing through the graft, the strip of Teflon felt, and the aorta (Fig 1A). The graft was then positioned carefully inside the aorta and the Teflon felt strip exterior, and the suture line was tightened with a nerve hook (Fig 1B). The inductive portion of the anastomosis was then performed either open or airtight, with particular attention to positioning the graft within the aorta, and placing the Teflon felt outside (Figs 1C and 1D). Thus the suture textile compresses the aortic wall between the Teflon felt and the graft fabric, and the sutures per se practise non pull on the aortic wall.
Fig 1 (A) The dorsum wall of the anastomosis is performed open up, with the sutures passing from the Dacron graft to the Teflon felt and then to the wall of the aorta. The first stitch is taken inside the graft. (B) The Teflon felt strip is then advisedly positioned outside the aorta; the graft is invaginated within the aorta, and the back suture line is tightened with a nerve hook. (C) The 2d needle, on the other suture end, is passed through the aorta and the Teflon felt, and the suture line is connected in either an open or closed way along the front end wall. Care is taken to place the graft inside the aorta and to position the Teflon felt advisedly on the outside. (D) The completed anastomosis. The almost important attribute of the anastomosis is that the suture does not pull directly on aortic tissue. In essence, the end of the aorta is clamped between the graft and the external Teflon felt by the running sutures. This not simply reduces needle pigsty bleeding at the time of the anastomosis, only also prevents progressive erosion of the suture through the aortic wall as stress is applied to the suture line by the pulsating aortic pressure level. The snugly fitted Teflon felt also heals securely to the aorta, every bit does the graft on the inside, and it is possible that the cuff of Teflon felt buffers the transition between the relatively noncompliant vascular graft and the variably compliant aorta.
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Biological glue, which consisted of concentrated fibrinogen and topical thrombin, was used in a few cases in the early 1990s, but glue containing denaturing agents (such as glutaraldehyde or formaldehyde) was never utilized. Tightly woven grafts soaked with albumin and later autoclaved were used in the early 1990s; thereafter, commercially prepared open up weave grafts impregnated with albumin (Hemashield) were used in all cases.
Results
During the interval under scrutiny, 34 patients, with a mean age of 55.1 years old (range 26 to 85 years onetime) returned to our institution and underwent reoperation for suture line disruptions following vascular graft-to-aorta anastomosis using Teflon felt. Eight patients (24%) were female person and 26 (76%) were male. Twenty-4 patients (71%) had been diagnosed as having dissection, half-dozen patients (18%) had the etiology of an atherosclerotic or degenerative aneurysm, 2 (ix%) suffered from Marfan's Syndrome at the time of initial surgical intervention, and the remaining 2 (half dozen%) had miscellaneous lesions. Eighteen patients (51%) had a history of hypertension. A mean number of 1.73 (range 1 to four) anastomoses using Teflon felt had been carried out in these patients. The initial operation was a Bentall process in 15 (44%), ascending aorta replacement in 9 (26%), total curvation replacement in 6 (18%), descending aorta replacement in ii (6%), thoracoabdominal repair in 1 (3%), and sinus of Valsalva repair in 1 patient (iii%). All previous operations were done at our establishment. No patient had had more i previous functioning.
The incidence of suture line disruption was 0.0052 per patient-yr, and 0.0034 per anastomosis-year. The average fourth dimension interval between the operations was 55.9 ± 51.2 months (range four to 180 months). At the time of presentation, the pseudoaneurysm or autopsy originated in fifteen% from the proximal ascending aortic anastomosis; in 53% from the distal ascending anastomosis; in 3% from both anastomoses in the ascending aortic part; in xv% from the proximal descending aortic anastomosis; and in 6% from the distal descending aortic anastomosis. In 3% of the patients the suture-line disruption was from a former Teflon felt-supported sinus of Valsalva repair and in 3% from the anastomosis to the innominate artery. In just 1 patient was there evidence of infection. In 12 patients (35%), the suture-line disruption caused a localized pseudoaneurysm; in 22 patients (65%), there was a dissection originating from the suture line.
The second functioning for pseudoaneurysm repair was done in ii patients (6%) emergently, in 13 (38%) urgently, and in xix patients (66%) equally an constituent process. The 2 procedures done under emergency conditions and the 13 urgently performed operations were exclusively done for the newly detected dissections originating from the suture line. The remaining 7 patients with dissections were done under elective circumstances, because the localized dissection was inadequate to discover preoperatively and just confirmed by the intraoperative findings. Reoperation involved ascending aortic or Bentall replacement in 11 patients (32%), and total arch replacement in 11 (32%). In 5 patients (xv%) a direct repair was feasible, and in vii (21%) a more specific reconstruction was done (see Table 2).
Table 2 Specific Clinical Data
| Previous Operation | Number of Patients | Location of Suture Line Disruption | Months Later on First Operation | Type of Repair |
|---|---|---|---|---|
| Bentall performance | 15 | 15 distal anastomosis | 55.1 ± 48.8 | 7 total arch replacement |
| 5 Bentall + proximal curvation | ||||
| 2 direct repair | ||||
| ane Bentall | ||||
| Ascending aortic replacement | ix | 5 proximal anastomosis | 32.3 ± 31.iii | iii Bentall + proximal curvation |
| 3 distal anastomosis | 64.0 ± 31.five | 2 directly repair | ||
| 1 both | 84 | 2 ascending replacement | ||
| one Bentall | ||||
| one total arch replacement | ||||
| Total arch replacement | vi | 1 proximal anastomosis | 72 | 3 total curvation replacement |
| 4 distal anastomosis | 46.0 ± 18.1 | 1 descending replacement | ||
| 1 innominate anastomosis | 48 | 1 distal arch + descending | ||
| ane ascending-descending featherbed | ||||
| Descending aortic replacement | 2 | 2 distal anastomosis | 132 ± 0 | 1 descending replacement |
| 1 distal arch + descending replacement | ||||
| Thoracoabdominal aortic replacement | 1 | one proximal anastomosis | 64 | 1 descending replacement |
| Sinus of Valsalva aneurysm repair | ane | one sinus of Valsalva repair | x | ane direct repair |
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Mean cardiopulmonary bypass (CPB) and aortic cross clamp times were 220 ± 88 minutes and 127 ± 63 minutes, respectively. Hypothermic circulatory arrest (HCA) with a mean temperature of xiii.4°C was used in 25 patients (74%) either to enable aortic repair or safe sternal re-entry. The mean HCA elapsing was 39 ± 14 minutes (see Table 3). The right axillary avenue was used late in our serial for CPB inflow in 5 patients (fifteen%); before patients were cannulated through the femoral artery, distal ascending aorta or aortic arch. The right atrium or femoral vein was used for venous return.
Tabular array iii Operative Data
| Mean | Range | |
|---|---|---|
| Total cardiopulmonary bypass time (min) | 220 | 50–415 |
| Hypothermic circulatory arrest (min) (used in 25 patients) | 39 | 11–70 |
| Selective antegrade cerebral perfusion (min) (used in six patients) | 66 | 23–132 |
| Esophageal temperature (°C) | xiii.four | 10.5–17.6 |
| Bladder temperature (°C) | 17.7 | 12.9–23.8 |
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An adverse result of hospital death or permanent stroke occurred in 8% of reoperated patients (3 of 34). There were two deaths during hospitalization, and one major permanent stroke.
The first patient who died was a 52-year-old male presenting with a 10.5 cm pseudoaneurysm with localized dissection on his distal graft-to-aorta anastomosis 36 months afterwards Bentall repair. He underwent emergent arch replacement, required reoperation for postoperative haemorrhage, prolonged respiratory therapy including tracheostomy, and transient hemodialysis. This patient died due to multiple organ failure on postoperative twenty-four hours 22.
The second patient suffering hospital expiry was a 63-year-old male presenting with a nine.2-cm pseudoaneurysm on his proximal graft-to-aorta anastomosis 64 months afterward thoracoabdominal aortic replacement. He was hospitalized for urgent descending aortic repair (first 8 cm) and demonstrated massive loose atheroma at all aneurysm sites. He died on postoperative mean solar day iv from severe neurologic injury.
The third patient with adverse issue (a permanent stroke) was a 72-year-former male who had undergone a total curvation replacement. He was admitted 72 months subsequently his first performance with a suture-line pseudoaneurysm at his proximal anastomosis site, and underwent elective arch rerepair. Intraoperative findings included a jell in the arch. He suffered a permanent stroke, but was able to be discharged to a rehabilitation facility on postoperative day 61 (see Table 4).
Table 4 Patient Related Values: Survivors Versus Patients With Adverse Issue
| Survivors n = 31 | Adverse Effect northward = 3 | |
|---|---|---|
| Age (years) | 54.v ± xiv.6 | 62.3 ± 8.ii |
| Time interval from initial operation | 56 ± 55 | 58 ± fifteen |
| Full cardiopulmonary bypass time (min) | 222 ± 85 | 201 ± 99 |
| Cross-clamp time (min) | 127 ± 63 | 123 ± 63 |
| Hypothermic circulatory | 37 ± 12 | 70 ± 0 |
| arrest (min) (used in | (23 patients) | (two patients) |
| 25 patients) |
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At that place were no postoperative complications in 21 of the patients (62%) who required reoperation for suture line disruption. The nearly frequent postoperative complications in the remaining patients were prolonged mechanical ventilator back up (greater than 48 hours) in 8 patients (24%), and transient neurologic dysfunction (TND) in half dozen (18%).
Annotate
Suture line disruptions are rare but severe complications after thoracic aortic repair, whether or non prosthetic materials are used for reconstruction. Whatsoever surgical problem with the anastomosis can give ascension to fake aneurysm formation or autopsy [
seven
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Pseudoaneurysms of the aorta subsequently cardiac surgery or chest trauma.
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,
8
- Kouchoukos N.T.
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11-yr experience with composite graft replacement of the ascending aorta and aortic valve.
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]. The interval between the original procedure and the occurrence of the false aneurysm or dissection is highly variable, only suture line disruption mandates reoperation in all patients [
]. The reported incidence of false aneurysm formation/dissection from suture lines varies from 7% to 25% [
x
- Barbetseas J.
- Crawford E.S.
- Safi H.J.
- Coselli J.S.
- Quinones Grand.A.
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Doppler echocardiographic evaluation of pseudoaneurysms complicating composite graft of the ascending aorta.
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].
Nosotros believe that the charge per unit of suture line disruption reported hither is authentic, considering only patient follow-up to the terminal documented CT browse showing an intact anastomosis was used in computing disruption rate. The rate of suture line disruption in this series is the lowest incidence hitherto reported. While it is truthful that the functioning of a carefully crafted Teflon felt-supported anastomosis may take slightly longer than use of simpler techniques, the modest amount of additional time required is unimportant in determining operative risk with electric current surgical techniques, especially hypothermic circulatory arrest and selective cognitive and visceral perfusion. As surgical bloodshed and morbidity continue to decline, the utility of various operative techniques in preventing long-term complications deserve standing re-evaluation. It is no longer an acceptable goal simply to accept the patient survive an aortic performance: each procedure should assure that the repair will maintain its integrity for decades thereafter.
Infirmary mortality for reoperations on the thoracic aorta varies from vi% to 19% [
ane
- Dossche Yard.Thousand.
- Tan M.Due east.
- Schepens M.A.
- Morshuis W.J.
- de la Rivere A.B.
Twenty-4 yr experience with reoperations after ascending or aortic root replacement.
- Crossref
- PubMed
- Scopus (40)
- Google Scholar
,
,
4
- Bachet J.Due east.
- Termignon J.L.
- Dreyfus G.
- et al.
Aortic dissection-prevalence, crusade and results of belatedly reoperations.
- PubMed
- Google Scholar
,
]. The early mortality rate is of class influenced past many factors: the urgency of operation; the nature of the underlying affliction; the technique of reoperation; the blazon of reintervention, and the indication for the procedure. In our serial, in which suture line aneurysms or dissection were the indication for reoperation, the charge per unit of adverse outcome (infirmary death or permanent stroke) among the 34 patients was eight% (three of 34).
With such a small incidence of suture line disruptions, it is non possible to draw any definitive conclusions about where such disruptions are most likely to occur, but their descriptions may nevertheless be of interest. In 28 of 34 patients (82%), suture line disruptions occurred in the ascending aortic wall or the proximal aortic arch; in simply 6 of 34 (18%) was the distal aortic arch or descending aortic graft-to-vessel connexion involved. Two of 3 patients in our series suffering an adverse outcome at reoperation had very large suture line aneurysms proximal to the innominate artery, where hemodynamic forces are arguably greatest.
In the ascending aorta, suture line disruptions were diagnosed at a hateful of 61.5 months after initial performance, whereas distal to the left subclavian artery, aneurysms were detected later, at a mean of 80.seven months postoperatively. The highly variable interval between the original procedure and the occurrence of the suture line disruption [
12
- Henriques J.P.Due south.
- de la Rivere A.B.
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Percutaneous occlusion of the entry to a leaking false aneurysm later on ascending aortic replacement for aortic autopsy type A facilitating surgical repair.
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, thirteen, 14] reinforces the need for lifelong surveillance: regular annual echocardiography and CT scanning or magnetic resonance imaging enable assessment of the integrity of anastomoses too as of possible distal progression of the aortic disease for which surgery was originally required.
Overall, our rate of suture line disruptions was very low: 1 per 191 patient-years, or i per 296 anastomosis-years. This suggests that using Teflon felt provides a secure, long-lasting graft-to-aorta anastomosis with minimal gamble of infection. Careful follow-up tin detect the rare instances of suture line failure, and reoperations can be accomplished with a low charge per unit of adverse outcome.
References
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Article Info
Publication History
Accepted: August 13, 2004
Identification
DOI: https://doi.org/10.1016/j.athoracsur.2004.08.028
Copyright
© 2005 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.
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