Cardiovascular Journal of Africa: Vol 28 No 6 (November/December 2017)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 29, No 1, January/February 2018 12 AFRICA
Reinforcement of suture lines with aortic eversion in
aortic replacement
Erhan Kaya
Abstract
Background: In this study, we describe the technique of ever-
sion of the native aortic tissue to prevent suture line complica-
tions, and report on our results with this technique.
Methods: A total of 42 patients who were operated on due to
aortic aneurysm were retrospectively assessed. In all patients,
an aortic segment of approximately 2 cm, which was left
both distally and proximally, was everted to form a double-
layer lumen and the grafts were anastomosed. Postoperative
outcomes and long-term follow-up results were assessed.
Results: Aortic root replacement was done in 14 cases and
eight subjects underwent concurrent coronary artery bypass
surgery. Postoperatively, the average volume of the drainage
was 375 ± 75 ml, and there were no re-operations. Twenty-
seven patients required blood transfusion.
Conclusion: Reinforcement of the anastomosis line via ever-
sion of the native aortic tissue reduced peri-operative blood
loss and pseudo-aneurysm and infection, with the advantage
of using viable tissue.
Keywords: suture technique, ascending aortic aneurysms, dissec-
tion, pledgetted
Submitted 4/5/16, accepted 12/1/17
Published online 16/1/18
Cardiovasc J Afr 2018; 29: 12–15
DOI: 10.5830/CVJA-2017-008
Bleeding at the suture line may be severe enough to necessitate
re-do cardiopulmonary bypass in patients undergoing surgical
prosthetic graft replacement due to aortic dissection or aneurysm.
Various techniques have been reported in an effort to prevent
this complication, including the use of pledgetted stitches and/
or bands during anastomosis, placement of additional sutures,
use of interrupted pledgetted sutures in the posterior region,
use of pledgetted sutures together with aortic inversion, use of
bands, inclusion of the graft within the graft, or the use of tissue
fibrinogen activators after anastomosis.1-4
The inflammatory response to foreign pledgetted material or
adhesions associated with the use of fibrin tissue adhesives may
increase the risk of infection in the long term or may complicate
dissection when re-operation is necessary. On the other hand,
external eversion of the aortic tissue at the site of anastomosis
to obtain a double-layered lumen to reinforce the suture line
may offer an alternative to pledgetted sutures or bands, allowing
minimal use of foreign material, preservation of tissue viability
at the suture line, and reducing the early risk of bleeding and
long-term risk of infection.
In this study, we present our results of a group of patients
who underwent ascending aortic tube graft replacement with
eversion of the aortic tissue in the stump and minimal or no
use of pledgetted sutures/bands to avoid postoperative bleeding,
pseudo-aneurysm and infection.
Methods
Patients undergoing surgery due to ascending aortic aneurysm
between 1 May 2014 and 31 December 2015 in our unit were
included in this retrospective study. Forty-two patients with a
diagnosis of ascending aortic aneurysm underwent surgery in
this period.
During surgery, aortic tissue was everted without the use of
pledgetted sutures or bands in all patients undergoing distal
anastomosis, as well as in all patients undergoing proximal
anastomosis with tube graft interposition only. In those
undergoing aortic root surgery, aortic tissue was everted on the
non-coronary site of the proximal anastomosis, while Teflon
band reinforcement was done on the right and left coronary sides
in those subjects lacking adequate tissue for eversion.
All procedures were performed under general anaesthesia and
cardiopulmonary bypass with a median sternotomy. The right
axillary artery was used for cannulation in all patients. During
surgery, arterial cannulation was performed through the right
axillary artery in all patients, while antegrade cerebral perfusion
and the open-anastomosis technique were used during distal
anastomosis. Except for one patient who had mitral valve repair
with bicaval venous cannulation, and another who underwent
atrial septal defect (ASD) closure, venous cannulation was
performed with a single venous cannula from the right atrium
in all patients.
Left heart decompression was achieved via the right superior
pulmonary vein and left atrial vent. After cross-clamping at the
distal ascending aorta, cardiac arrest was achieved with blood
cardioplegia through the aorta in patients with aortic sufficiency,
while in those with aortic valve insufficiency, initial cardioplegia
was achieved with the retrograde coronary sinus route, followed
by selective coronary ostia after aortotomy. In all patients,
myocardial protection was maintained continuously via the
coronary sinuses after antegrade cardioplegia.
After opening the aneurysmal sac, it was transected proximally
and distally, while care was taken to leave approximately 2 cm of
aortic tissue, allowing eversion at both ends. Similarly, in patients
undergoing coronary re-implantation, aortic tissue adequate for
eversion was left intact proximally on the non-coronary side.
In our unit, we perform re-implantation of the coronary ostia
by leaving a wide margin of aortic tissue around the coronary
ostia, using the eversion technique. A proximal anastomosis was
then performed by placing the sutures first through the double-
Private Pendik Regional Hospital, Department of
Cardiovascular Surgery, Istanbul, Turkey
Erhan Kaya, MD,