Introduction

Article Outline

• Ideal Exposure for Extended Arch Replacement: Bilateral Anterior Thoracotomy or L-Shaped Incision?
• Gore-Tex in the Right Ventricular Outflow Tract: Monocusp vs. Bicusp
• Superior Vena Cava and Pulmonary Artery Resections for Lung Cancer
• Copyright

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Ideal Exposure for Extended Arch Replacement: Bilateral Anterior Thoracotomy or L-Shaped Incision? 

In this issue of Operative Techniques in Thoracic and Cardiovascular Surgery, Drs. Kouchoukos and Tominaga describe their techniques for extended aortic arch replacement. Dr. Kouchoukos describes the technique which he has pioneered, namely bilateral anterior thoracotomy for replacement of the ascending aorta, aortic arch and descending thoracic aorta. This technique employs axillary cannulation, and an arch-first approach, which entails cerebral revascularization with a four branch prosthesis, antegrade cerebral perfusion and early establishment of complete cerebral perfusion. The proximal and distal reconstruction then is accomplished, completing the procedure. Dr. Tominaga describes the L-incision of extended aortic arch replacement. This technique employs cannulation of both axillary and femoral arteries. The procedure is characterized by proximal aortic reconstruction first, followed by cerebral vessel reconstruction with a branched prosthesis employing selective antegrade perfusion of each of the cerebral vessels. This technique differs from Dr. Kouchoukos' who utilizes only selective antegrade perfusion of the right internal carotid. Dr. Tominaga's technique further differs from that of Dr. Kouchoukos in that the descending thoracic aorta is reconstructed with a reverse elephant trunk. This is then everted from the descending thoracic aorta and anastomosed to the arch graft, which is brought beneath the pedicle of the phrenic and vagal nerves.

These are two ingenious and innovative approaches to complex reconstruction of the aortic arch and proximal descending thoracic aorta. A troublesome area has proven to be the upper intercostal vessels which are obscured by the phrenic and vagal nerve pedicle and can be extremely difficult to access and control. With that caveat, despite the magnitude of these procedures, these techniques are applicable to patients with complex disease of their ascending aorta, transverse aortic arch and proximal descending thoracic aorta, and offer viable alternatives to more conventional staged approaches.

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Gore-Tex in the Right Ventricular Outflow Tract: Monocusp vs. Bicusp 

The congenital section of this issue examines reconstruction of the right ventricular outflow tract with hand-fashioned polytetrafluoroethylene (PTFE, Gore-Tex) valves. This approach is increasingly used to provide some degree of pulmonary competence in patients undergoing both primary and repeat operations. Mark Turrentine, Mark Rodefeld and John Brown from Indiana University present the use of PTFE in a monocusp configuration, an approach they have now used in more than 200 implants. Jim Quintessenza from St. Petersburg presents his novel use of PTFE in a bicuspid configuration. These two articles provide excellent illustrations of the technical details involved in PTFE reconstruction of the right ventricular outflow tract.

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Superior Vena Cava and Pulmonary Artery Resections for Lung Cancer 

This section contains two articles that highlight combined pulmonary artery and bronchial artery sleeve resections as well as concomitant resection of the superior vena cava secondary to involvement by lung cancer. While it is uncommon to need to do these operations, familiarity of these types of procedures is needed in order to ensure that patients can receive a R0 resection. In the first article, Drs. Venuta and Rendina describe their approach for performing both tangential and sleeve resections of the pulmonary artery when combined with an anatomic resection of the lung. This nicely illustrated article describes several different clinical scenarios and is a valuable addition to the literature for the technical aspects of these procedures. In the companion article, Dr. Jones describes his approach to resection of the superior vena cava when involved with a lung cancer. These two articles provide excellent illustrations and technical caveats which will allow the thoracic surgeon to perform both operations safely and with success.