[[700 Technical Outline of Repair of Aortic Dissection]] DateCreated:: [[<% tp.file.creation_date("YYYYMMDD") %>]] DateLastModified:: <% tp.file.last_modified_date("YYYYMMDD") %> FileFolder:: <%tp.file.folder()%> NoteType:: Status:: Priority:: Review:: SourceType:: Author:: Rating:: External Links: - Note Links: - # Distal Anastomosis - Arrange a drop sucker so that it enters the field from the cephalad end. - Drape it over the anterior lip of the target aorta - Pin the proximal end of the dacron graft to towels on the caudal end of the sternotomy with a Kelly or mosquito clamp - Adopt a convention where the most anterior aspect of the targe aorta is at noon, the most posterior is at six o’clock. - It may be helpful to orient the black lines on the graft at 3 and 9 o’clock - If a side arm graft is used for intended reperfusion down the graft you will want to position the side arm so that it is oriented to 11 o’clock - Often the length of aorta that will be replaced is surprisingly short in a standard hemi-arch, using a short length of graft shorter on the inner curvature. - Initial instinct will be to position the side arm at 9 o’clock where there is more room on the greater curvature. - If it is positioned at 9 o’clock or less, there is a tendency for the side arm to kink and interfere with flows - ![[Ascending Aortic Replacement with Side-Arm Graft at Judicious and Injudicious Angles.jpeg]] - Drape the distal end of the proximally secured graft close to the target aorta - As usual, begin the anastomosis at 4 o’clock - Pass one end of a 4-0 prolene inside out through the graft, then through all layers of the teflon sandwich target aorta - Lay out one third of the length of the other end of the prolene away from you, weigh it down with a rubber-shod and weigh down the rubber-shod with a tubing clamp slid down one of its finger rings. - Some people put a lot of stock in telescoping the graft so that fits inside the target aorta, but I have not found this necessary or worthy of extra effort. - Sew towards yourself to eight o’clock - Taking advantage of the weighted end, and maintaining a one-third, two-thirds relationship, sequentially nerve hook the back row of the anastomosis to tighten the prolene. You will have a blunt nerve hook in one hand, and the leading end of the suture in the other. Your assistant will have another blunt nerve hook in one hand, and will open the anterior anastomosis with a Debakey forceps in the other or pull as necessary on the trailing end of the prolene. - Hook every other prolene as tight as you can, then your assistant will replace your hook with theirs to maintain the current tension, while you move to the next loop. As you pull that loop, the assistant will allow the loop to slide into place. - This hooking can be done from inside or outside the anastomosis. - Note any gaps in the back wall - Temporarily weight the leading end of the prolene with a rubber-shod and weigh down the rubber-shod with a tubing clamp slid down one of its finger rings. - This is a good time to reinforce any gaps noted in the back wall with internal or external figure of eight 4-0 prolene - Take a look at the length of either end of the prolene. Will it be enough to comfortably complete the anastomosis? - If so, continue - If not, place a single 4-0 prolene close to the entry point of the end you want to lengthen, tie it down, and tie the free end to this. You now have a longer length of suture to work with, and neighboring loops of prolene are no longer in danger of loosening and need no repeat hooking. - Trim the graft a little if desired to make manipulation easier- this isn’t the final trim. - Remove the drop sucker from its current position, and drape it from the caudal of the sternotomy, into the graft and over the back of the anastomosis so it drains the area without getting in the way of the front wall. - Take up the leading end of the 4-0 prolene from where you left it at eight o’clock, and continue to sew up to 11 o’clock - Switch the rubber shod/tubing clamp weight to the leading end, and take up the other end. - Sew towards yourself from 4 o’clock to 11 o’clock to complete the anastomosis - Nerve hook again, tie down.