Combined median sternotomy and posterior lateral thoracotomy: a method for proximal and distal thoracic aortic exposure

Total arch replacement for thoracic aortic aneurysm via median sternotomy with or without left anterolateral thoracotomy

BACKGROUND

Thoracic aneurysms involving the ascending aorta, arch, and descending aorta are usually approached in a series of operations. Here, we report our clinical experience with total arch replacement through a median sternotomy with or without left anterolateral thoracotomy, using a technique that preserves the anterior wall of the distal arch to avoid injuring the left recurrent and phrenic nerves.

METHODS

Between March 1999 and February 2001, 32 consecutive patients underwent total arch replacement through a median sternotomy alone (median group, n = 23) or in combination with a left anterolateral thoracotomy (LAT group, n = 9). In all cases, antegrade hypothermic selective cerebral perfusion was used in conjunction with mild hypothermic visceral perfusion (cool head-warm body perfusion).

RESULTS

There were no in-hospital deaths and two late deaths. One patient in the median group had permanent neurological dysfunction postoperatively. There were no significant differences between the two groups in bypass time, cardiac ischemic time, respiratory assist time, beginning peroral intake, hospital stay, or postoperative respiratory function. The distal anastomosis level was significantly lower in the LAT group (thoracic vertebra level 7.1 +/- 1.5 vs 5.6 +/- 0.5, p = 0.0015).

CONCLUSIONS

Preservation of the anterior wall in the distal arch may decrease in-hospital mortality and perioperative neurological dysfunction after total arch replacement. Total arch replacement through a median sternotomy with left anterolateral thoracotomy allowed expeditious and extended replacement of the aorta without increasing postoperative respiratory complications.