Background: Even though the median sternotomy is the standard approach for surgery involving the aortic arch, access to the site of distal anastomosis is problematic when the aortic pathology involves the distal arch. We recently developed an "L-incision" approach (a combination of a left anterior thoracotomy and upper half median sternotomy) for total arch replacement.
Methods: We reviewed our surgical technique and operative results for 11 patients who underwent total aortic arch replacement through the L-incision between July 1999 and July 2000. With a patient in a left anterolateral position, a left anterior thoracotomy was performed through the fourth to sixth intercostal space. An upper half median sternotomy followed. Operative exposure was enhanced with spring retractors. The proximal anastomosis (between the four branched graft and ascending aorta) was accomplished first. Upon completion of the proximal anastomosis, the heart was reperfused from one branch of the graft. The three arch vessels were subsequently reconstructed under deep hypothermia and retrograde cerebral perfusion. Antegrade cerebral perfusion was accomplished through the graft as the distal anastomosis (between the graft and descending thoracic aorta) was performed.
Results: No early operative deaths were observed. One patient sustained a permanent neurologic deficit. A transient recurrent laryngeal nerve palsy lasting 1 month occurred in 1 patient. No patient required reoperations for bleeding, nor did any patient develop a postoperative phrenic nerve palsy, aspiration pneumonia, or renal dysfunction.
Conclusions: The L-incision allows extensive replacement of the aortic arch and is associated with a low incidence of postoperative bleeding and respiratory insufficiency.