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Operative Techniques in Thoracic and Cardiovascular Surgery
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Cardiac surgery| Volume 14, ISSUE 1, P12-22, March 2009

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Aortic Fenestration for Dissection

Open ArchiveDOI:https://doi.org/10.1053/j.optechstcvs.2009.02.001
Aortic Fenestration for Dissection
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      Aortic fenestration has been used at our institution since 1973. The indications for this procedure and the technique have evolved, now being exclusively performed for patients with acute limb and/or organ ischemia secondary to descending aortic dissection. Paramount to the success of this procedure is early recognition and quick intervention to avoid irreversible end-organ damage and fixed thrombosis in the false lumen. Physical examination and diagnostic computed tomography can aid in obtaining a quick diagnosis. Contraindications to aortic fenestration include delayed diagnosis (after 48 hours the success of re-establishing perfusion is low secondary to thrombus burden). Also fenestration should not be done in the manner described in this article unless the dissection flap reaches the level of the infrarenal aorta. Note that patients with ruptured descending aortic dissections or aneurysms can also present with malperfusion, and fenestration is contraindicated as sole therapy in this population. At our institution the use of aortic fenestration has yielded excellent results with restoration of limb/organ perfusion in nearly all cases with low morbidity and mortality.
      • Elefteriades J.A.
      • Hammond G.L.
      • Gusberg R.J.
      • et al.
      Fenestration revisited A safe and effective procedure for descending aortic dissection.
      Arch Surg. 1990; 125: 786-790
      , 
      • Elefteriades J.A.
      • Hartleroad J.
      • Gusberg R.J.
      • et al.
      Long-term experience with descending aortic dissection: The complication-specific approach.
      Ann Thorac Surg. 1992; 53 (discussion 20-21): 11-20
      , 
      • Morales D.L.
      • Quin J.A.
      • Braxton J.H.
      • et al.
      Experimental confirmation of effectiveness of fenestration in acute aortic dissection.
      Ann Thorac Surg. 1998; 66: 1679-1683

      Operative Technique

      Figure thumbnail gr1
      Figure 1The patient is positioned on the operating table in a semi-supine position with the left flank elevated. This is achieved by placing a roll under the patient's left flank. After skin preparation and draping, an oblique incision is made from the midline to the posterior axillary line centered at the level of the umbilicus.
      Figure thumbnail gr2
      Figure 2After using electrocautery to dissect the soft tissue, the external oblique muscle is encountered. The fascia is opened and the muscle is split in the direction of its fibers. The internal oblique and transversus abdominus are incised and split in a similar manner. After opening the transversus, care should be taken to avoid entering the peritoneal cavity. Occasionally the muscle layers are divided rather than merely split to improve exposure.
      Figure thumbnail gr3
      Figure 3The intact peritoneal sac is retracted medially to expose the retroperitoneal space. Dissection in this plane usually consists of dividing thin fibers bluntly to expose the aorta. We use an abdominal Omni retractor system to maintain exposure, relying on the deep body wall blades to maintain cephalad and caudal exposure. a. = artery; IVC = inferior vena cava; v. = vein.
      Figure thumbnail gr4
      Figure 4Dissection along the aorta is done to a level just below the renal arteries proximally and just above the inferior mesenteric artery distally. Care must be taken to dissect the aorta circumferentially between these two points to aid in the technique of the repair. Systemic heparin sulfate is then administered. Straight aortic vascular clamps are applied below the renal arteries proximally and above the inferior mesenteric artery distally. a. = artery; IMA = inferior mesenteric artery; v. = vein.
      Figure thumbnail gr5
      Figure 5The mobilized aorta is then completely transected in transverse fashion between the clamps and the intimal flap is identified proximally and distally.
      Figure thumbnail gr6
      Figure 6Fenestration of the intimal flap is then performed on the proximal aorta. This is accomplished by excising as much intima as possible, in both circumferential and longitudinal extent toward the proximal clamp.
      Figure thumbnail gr7
      Figure 7The dissection in the distal open end of the aorta is then repaired. A 4-0 polypropylene suture in continuous over-and-over fashion is used to re-approximate the intima to the adventitial layer of the aorta.
      Figure thumbnail gr8
      Figure 8The fenestrated proximal end is then re-anastamosed to the repaired distal end of the aorta. A 4-0 polypropylene suture in continuous over-and-over fashion is used to suture the adventitial layer proximally to the full-thickness aorta distally. De-airing of the aorta is also performed by flashing the clamps before tying the sutures.
      Figure thumbnail gr9
      Figure 9The aortic clamps are removed, allowing re-institution of blood flow throughout the entire aorta. At this point, the suture line is checked meticulously for hemostasis and areas of bleeding can be stopped by using 5-0 polypropylene sutures in interrupted fashion, although this is rarely necessary.
      Figure thumbnail gr10
      Figure 10After hemostasis is achieved, the Omni retractor is removed, and closure of the abdominal wall fascial layers is performed by using 2-0 Vicryl suture in a continuous fashion.

      Conclusions

      All patients requiring this procedure are critically ill, yet the operation is generally well tolerated, is quick and efficient, and results in minimal hemodynamic instability or blood loss. Our experience suggests that using this technique of fenestrating the infrarenal aorta restores perfusion to organs both above and below the fenestration site. By decompressing the tense false lumen, obstruction of the true lumen proximally is relieved, and by reconstituting the aorta distal to the fenestration, blood flow is redirected to the true lumen. Results from our series show successful organ reperfusion in >90% of cases and long-term follow-up has resulted in no aortic or ischemic problems. Although endovascular techniques for balloon fenestration with stenting have been described with mixed results, these techniques can be very time consuming. This open retroperitoneal procedure can be performed quickly, without specialized endovascular or imaging equipment. Because we feel that the paramount objective is to restore perfusion as quickly and effectively as possible, we advocate this open technique. In contradiction to direct graft replacement on the aorta, the fenestration technique is performed retroperitoneally (without body cavity entry), requires no prosthetic aortic graft, requires no cardiopulmonary bypass, and is directed specifically to restoration of organ flow.

      References

        • Elefteriades J.A.
        • Hammond G.L.
        • Gusberg R.J.
        • et al.
        Fenestration revisited.
        Arch Surg. 1990; 125: 786-790
        View in Article
        • Elefteriades J.A.
        • Hartleroad J.
        • Gusberg R.J.
        • et al.
        Long-term experience with descending aortic dissection: The complication-specific approach.
        Ann Thorac Surg. 1992; 53 (discussion 20-21): 11-20
        View in Article
        • Morales D.L.
        • Quin J.A.
        • Braxton J.H.
        • et al.
        Experimental confirmation of effectiveness of fenestration in acute aortic dissection.
        Ann Thorac Surg. 1998; 66: 1679-1683
        View in Article

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      DOI: https://doi.org/10.1053/j.optechstcvs.2009.02.001

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