An L-Shaped Incision for an Extensive Thoracic Aortic Aneurysm and Coronary Artery Bypass Using the Left Internal Thoracic Artery

Abstract

An L-shaped incision combining an upper half mid-sternotomy and a left antero-lateral thoracotomy at the fourth intercostal space has been proposed by several authors for extensive aneurysms involving the aortic arch and the proximal thoracic descending aorta. This approach usually requires the division of the left internal thoracic artery at its mid position, thus making it unusable for coronary artery bypass. We herein report a modified surgical approach for simultaneous extensive arch and proximal thoracic descending aorta replacement and coronary artery bypass using the left internal thoracic artery combining a left antero-lateral thoracotomy at the sixth intercostal space and upper mid-sternotomy. The visualization of the whole diseased aorta down to the level below the hilum of the left lung was good, and the integrity of the left internal thoracic artery graft was preserved by early heparin administration before sternotomy.

Key Words

Thoracic Aortic Aneurysm - Coronary Artery Bypass - Mammary Arteries

• References

• 1 Tominaga R, Kurisu K, Ochiai Y, Nakashima A, Masuda M, Morita S. , et al. Total aortic arch replacement through the L-incision approach. Ann Thorac Surg 2003; 75: 121-125 DOI: 10.1016/S0003-4975(02)04300-X
• 2 Borst HG, Walterbusch G, Schaps D. Extensive aortic replacement using "elephant trunk" prosthesis. Thorac Cardiovasc Surg 1983; 31: 37-40 DOI: 10.1055/s-2007-1020290
• 3 Kouchoukos NT, Mauney MC, Masetti P, Castner CF. Single-stage repair of extensive thoracic aortic aneurysms: experience with the arch-first technique and bilateral anterior thoracotomy. J Thorac Cardiovasc Surg 2004; 128: 669-6676 DOI: 10.1016/j.jtcvs.2004.06.037
• 4 Sato E, Olson SH, Ahn J, Bundy B, Nishikawa H, Qian F. , et al. Intraepithelial CD8(+) tumor-infiltrating lymphocytes and a high CD8(+)/regulatory T cell ratio are associated with favorable prognosis in ovarian cancer. P Natl Acad Sci USA 2005; 102: 18538-18543 DOI: 10.1073/pnas.0509182102
• 5 Abe T, Kamikubo Y, Taneichi T, Terada T, Sugiura J, Sakurai T. , et al. Right heart failure secondary to compression of the right pulmonary artery by a large proximal aortic aneurysm. Circulation 128: 1588-1589 DOI: 10.1161/CIRCULATIONAHA.113.001546
• 6 Kazui T, Yamashita K, Washiyama N, Terada H, Bashar AH, Suzuki T. , et al. Usefulness of antegrade selective cerebral perfusion during aortic arch operations. Ann Thorac Surg 2002; 74: S1806-S1809 discussion S25-S32. DOI: 10.1016/S0003-4975(02)04150-4
• 7 Berdajs D, Turina MI. Operative Anatomy of the Heart. Heidelberg Dordrecht London New York: Springer-Verlag; 2011. p. 110 DOI: 10.1007/978-3-540-69229-4