Miniaccess open repair of descending thoracic aorta

Abstract

Central MessageThe miniaccess open repair of descending thoracic aorta showed favorable early outcomes and acceptable safety in selected patients.See Commentary on page 31. The miniaccess open repair of descending thoracic aorta showed favorable early outcomes and acceptable safety in selected patients. See Commentary on page 31. Thoracic endovascular repair (TEVAR) has emerged as an effective treatment option for descending thoracic aorta (DTA) diseases due to less invasiveness and better early outcomes compared with open repair. Nevertheless, potential endoleak, risks of later reintervention, and less effectiveness in challenging aortic anatomy are major limitations of TEVAR, and these still leave questions regarding its long-term durability.1Goodney P.P. Travis L. Lucas F.L. Fillinger M.F. Goodman D.C. Cronenwett J.L. et al.Survival after open versus endovascular thoracic aortic aneurysm repair in an observational study of the Medicare population.Circulation. 2011; 124: 2661-2669Crossref PubMed Scopus (195) Google Scholar, 2Harky A. Kai Chan J.S. Ming Wong C.H. Bashir M. Open versus endovascular repair of descending thoracic aortic aneurysm disease: a systematic review and meta-analysis.Ann Vasc Surg. 2019; 54: 304-315.e5Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar, 3Fujikawa T. Yamamoto S. Oshima S. Ozaki K. Shimamura J. Asada H. et al.Open surgery for descending thoracic aorta in an endovascular era.J Thorac Cardiovasc Surg. 2019; 157: 2168-2174Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar For these reasons, open DTA repair remains the most effective treatment option for DTA diseases, and its surgical outcomes have been improving with advances in surgical techniques and perioperative management. Open DTA repair requires extended thoracotomy involving a large skin incision with division of thoracic muscles and cutting costal cartilage/bone, which in turn carries extensive surgical trauma and its associated complications. To overcome these limitations, we have adopted miniaccess open DTA repair. Herein, we present our experiences and early outcomes of this procedure. Miniaccess open DTA repair is defined as limited skin incision (6-10 cm), sparing 2 thoracic muscles (ie, latissimus dorsi and serratus anterior muscles), saving costal cartilage/bone without cutting, and utilization of thoracoscopy and miniaccess instruments. All cases requiring elective aortic intervention on DTA were considered for this miniaccess surgery if the longitudinal extent of the lesion was within 15 cm in the aim of offering more durable repair with minimum surgical trauma. Exclusion criteria were emergent cases and high estimated surgical risks (ie, severe lung disease or chronic kidney disease) in which the conventional open thoracotomy or TEVAR were the preferable option. Cerebrospinal fluid drainage was not conducted in all patients because the extent of the lesion was limited to involving the upper or middle DTA, and patients were relatively young with low-risk profiles at baselines. The patient was positioned on a bean bag for right lateral decubitus position similar to the position for conventional DTA or thoracoabdominal aortic open repair, but with the left shoulder pulled upward only (not anteriorly) because the main incision does not require lifting up the scapula anteriorly. A skin incision was made and 2 thoracic muscles were divided and spared along the planes without cutting. The access was made through the fourth or fifth intercostal space. A port for 10-mm thoracoscopy was inserted onto the sixth or seventh intercostal space, which were 2 levels lower than the main incision. With the operation view obtained either via direct vision or thoracoscopy, DTA was dissected from the surrounding structures with miniaccess instruments (Figure 1, A and B). Cardiopulmonary bypass was established through left femoral vessels under normothermic condition; however, moderate hypothermic circulatory arrest