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Stanford type A and arch lesions, whereas endovascular therapy is preferred in Stanford type B disease. In hemodynamically stable polytrauma patients with aortic injury in combination with open brain or bone injury, it is reasonable to first
treat accompanying injuries with high risk of bleeding and postpone aortic surgery [12].
FOLLOW-UP
All patients with AAS irrespective of the way of treatment should maintain blood pressure control and have a follow-up
surveillance with CT or MRI imaging to detect secondary complications such as progression of dissection, aortic dilatation,
or rupture. Preferably, the same imaging technique should be used to ensure comparability of scans and avoid misinterpretation of only technical differences in images. Suggested follow-up intervals are 3, 6, and 12 months after initial operation or
intervention, afterward yearly, in stable conditions every 2 years.
REFERENCES
[1] Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, Eggebrecht H, Evangelista A, Falk V, Frank H, Gaemperli O, Grabenwöger M,
Haverich A, Iung B, Manolis AJ, Meijboom F, Nienaber CA, Roffi M, Rousseau H, Sechtem U, Sirnes PA, Allmen RS, Vrints CJ, ESC Committee
for Practice Guidelines. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases
of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of
Cardiology (ESC). Eur Heart J 2014;35(41):2873–926.
[2] Daily PO, Trueblood HW, Stinson EB, Wuerflein RD, Shumway NE. Management of acute aortic dissections. Ann Thorac Surg 1970;10:237–47.
[3] DeBakey ME, Henly WS, Cooley DA, Morris Jr GC, Crawford ES, Beall Jr AC. Surgical management of dissecting aneurysms of the aorta. J Thorac
Cardiovasc Surg 1965;49:130–49.
[4] Svensson LG, Labib SB, Eisenhauer AC, Butterly JR. Intimal tear without hematoma: an important variant of aortic dissection that can elude current
imaging techniques. Circulation 1999;99:1331–6.
[5] Augoustides JG, Geirsson A, Szeto WY, Walsh EK, Cornelius B, Pochettino A, Bavaria JE. Observational study of mortality risk stratification by
ischemic presentation in patients with acute type A aortic dissection: the Penn classification. Nat Clin Pract Cardiovasc Med 2009;6(2):140–6.
[6] Tsai TT, Nienaber CA, Eagle KA. Acute aortic syndromes. Circulation 2005;112:3802–13.
[7] Howard DP, Banerjee A, Fairhead JF, Perkins J, Silver LE, Rothwell PM. Population-based study of incidence and outcome of acute aortic dissec-
tion and premorbid risk factor control: 10-year results from the Oxford Vascular Study. Circulation 2013;127:2031–7.
[8] Hagan PG, Nienaber CA, Isselbacher EM, Bruckman D, Karavite DJ, Russman PL, Evangelista A, Fattori R, Suzuki T, Oh JK, Moore AG, Malouf
JF, Pape LA, Gaca C, Sechtem U, Lenferink S, Deutsch HJ, Diedrichs H, Marcos y, Robles J, Llovet A, Gilon D, Das SK, Armstrong WF, Deeb GM,
Eagle KA. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA 2000;283:897–903.
[9] Sampson UKA, Norman PE, Fowkes GR, Aboyans V, Song Y, Harrell FE, Forouzanfar MH, Naghavi M, Denenberg JO, McDermott MM, Criqui
MH, Mensah GA, Ezzati M, Murray C. Global and regional burden of aortic dissection and aneurysms. Global Heart 2014;8:171–80.
[10] Evangelista A, Mukherjee D, Mehta RH, O’Gara PT, Fattori R, Cooper JV, Smith DE, Oh JK, Hutchison S, Sechtem U, Isselbacher EM, Nienaber
CA, Pape LA, Eagle KA, International Registry of Aortic Dissection (IRAD) Investigators. Acute intramural hematoma of the aorta: a mystery in
evolution. Circulation 2005;111(8):1063–70.
[11] Williams JA, Loeys BL, Nwakanma LU, Dietz HC, Spevak PJ, Patel ND, François K, DeBacker J, Gott VL, Vricella LA, Cameron DE. Early surgi-
cal experience with Loeys-Dietz: a new syndrome of aggressive thoracic aortic aneurysm disease. Ann Thorac Surg 2007;83(2):757–63.
[12] Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey Jr DE, Eagle KA, Hermann LK, Isselbacher EM, Kazerooni EA, Kouchoukos
NT, Lytle BW, Milewicz DM, Reich DL, Sen S, Shinn JA, Svensson LG, Williams DM, American College of Cardiology Foundation/American
Heart Association Task Force on Practice Guidelines; American Association for Thoracic Surgery; American College of Radiology; American
Stroke Association; Society of Cardiovascular Anesthesiologists; Society for Cardiovascular Angiography, Interventions; Society of Interventional
Radiology; Society of Thoracic Surgeons; Society for Vascular Medicine. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guide-
lines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/
American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology,
American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of
Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation 2010;121(13):e266–369.
[13] Urbanski PP, Wagner M. Acute non-A-non-B aortic dissection: surgical or conservative approach? Eur J Cardiothorac Surg 2016;49(4):1249–54.
[14] Nauta FJ, Tolenaar JL, Patel HJ, Appoo JJ, Tsai TT, Desai ND, Montgomery DG, Mussa FF, Upchurch GR, Fattori R, Hughes GC, Nienaber CA,
Isselbacher EM, Eagle KA, Trimarchi S, All International Registry of Acute Aortic Dissection (IRAD) Investigators. Impact of retrograde arch
extension in acute type B aortic dissection on management and outcomes. Ann Thorac Surg 2016. pii:S0003-4975(16)30493-3.
[15] Tsagakis K, Konorza T, Dohle DS, Kottenberg E, Buck T, Thielmann M, Erbel R, Jakob H. Hybrid operating room concept for combined diagnos-
tics, intervention and surgery in acute type A dissection. Eur J Cardiothorac Surg 2013;43(2):397–404.
[16] Song SW, Yoo KJ, Shin YR, Lim SH, Cho BK. Effects of intermittent lower body perfusion on end-organ function during repair of acute DeBakey
type I aortic dissection under moderate hypothermic circulatory arrest. Eur J Cardiothorac Surg 2013;44(6):1070–4.
[17] Martens A, Koigeldiyev N, Beckmann E, Fleissner F, Kaufeld T, Krueger H, Stanelle D, Puntigam J, Haverich A, Shrestha M. Do not leave the heart
arrested. Non-cardioplegic continuous myocardial perfusion during complex aortic arch repair improves cardiac outcome. Eur J Cardiothorac Surg
2016;49(1):141–8.
Surgical Treatment of Acute Aortic Syndrome Chapter | 45 499
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[18] Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC); European Association for Cardio-
Thoracic Surgery (EACTS), Vahanian A, Alfieri O, Andreotti F, Antunes MJ, Barón-Esquivias G, Baumgartner H, Borger MA, Carrel TP, De Bonis
M, Evangelista A, Falk V, Iung B, Lancellotti P, Pierard L, Price S, Schäfers HJ, Schuler G, Stepinska J, Swedberg K, Takkenberg J, Von Oppell UO,
Windecker S, Zamorano JL, Zembala M. Guidelines on the management of valvular heart disease (version 2012). Eur Heart J 2012;33(19):2451–96.
[19] Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin 3rd JP, Guyton RA, O’Gara PT, Ruiz CE, Skubas NJ, Sorajja P, Sundt 3rd TM, Thomas
JD, ACC/AHA Task Force Members. 2014 AHA/ACC Guideline for the Management of Patients with Valvular Heart Disease: a report of the
American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014;129(23):e521–643.
[20] Saczkowski R, Malas T, Mesana T, de Kerchove L, El Khoury G, Boodhwani M. Aortic valve preservation and repair in acute Type A aortic dissec-
tion. Eur J Cardiothorac Surg 2014;45(6):e220–6.
[21] Di Bartolomeo R, Pantaleo A, Berretta P, Murana G, Castrovinci S, Cefarelli M, Folesani G, Di Eusanio M. Frozen elephant trunk surgery in acute
aortic dissection. J Thorac Cardiovasc Surg 2015;149(Suppl. 2):105–9.
[22] Ulug P, McCaslin JE, Stansby G, Powell JT. Endovascular versus conventional medical treatment for uncomplicated chronic type B aortic dissec-
tion. Cochrane Database Syst Rev 2012;11:CD006512.
[23] Pradhan S, Elefteriades JA, Sumpio BE. Utility of the aortic fenestration technique in the management of acute aortic dissections. Ann Thorac
Cardiovasc Surg 2007;13(5):296–300.
[24] Núñez-Gil IJ, Bautista D, Cerrato E, Salinas P, Varbella F, Omedè P, Ugo F, Ielasi A, Giammaria M, Moreno R, Pérez-Vizcayno MJ, Escaned J,
De Agustin JA, Feltes G, Macaya C, Fernández-Ortiz A, Registry on Aortic Iatrogenic Dissection (RAID) Investigators. Incidence, Management,
and Immediate- and Long-Term Outcomes After Iatrogenic Aortic Dissection During Diagnostic or Interventional Coronary Procedures. Circulation
2015;131(24):2114–9.
[25] Song JK, Yim JH, Ahn JM, Kim DH, Kang JW, Lee TY, Song JM, Choo SJ, Kang DH, Chung CH, Lee JW, Lim TH. Outcomes of patients with
acute type a aortic intramural hematoma. Circulation 2009;120(21):2046–52.
[26] Kitai T, Kaji S, Yamamuro A, Tani T, Tamita K, Kinoshita M, Ehara N, Kobori A, Nasu M, Okada Y, Furukawa Y. Clinical outcomes of medical ther-
apy and timely operation in initially diagnosed type a aortic intramural hematoma: a 20-year experience. Circulation 2009;120(Suppl. 11):S292–8.
Chapter 46
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Minimally Invasive Surgery for Aortic
Aneurysms
Magdalena Rufa, Adrian Ursulescu, Alina Stan, Marc Albert, Hardy Baumbach, Ulrich F.W. Franke
Robert Bosch Hospital, Stuttgart, Germany
Chapter Outline
Introduction 501
Definition, Etiology, and Classification 501
Indications for Surgical Treatment 502
Surgical Approach and Surgical Technique 502
Standard Approach in Our Institution for Thoracic
Aneurysm Surgery 502
Surgical Technique According to Pathology 505
Results and Discussion 505
Conclusion 507
References 507
INTRODUCTION
Aortic aneurysms are characterized by an increased risk of dissection or rupture. The therapeutic goal is the elimination
of the aneurysm. Depending on the diseased portion of the aorta, current standard therapies are either surgical or interventional-endovascular, or hybrid procedures, which is a combination of both.
In relation to the subject of this chapter, the surgical treatment is still the gold standard for the aortic root, ascending
aorta up to aortic arch aneurysms. This section of the aorta is also accessible via the now established upper partial sternotomy. Thus, it is possible to perform all standard procedures in this aortic section as minimally invasive procedures by
means of surgical access.
DEFINITION, ETIOLOGY, AND CLASSIFICATION
The most common condition of the thoracic aorta requiring surgical treatment is the aneurysm [1]. Due to a weakening
of the aortic wall accompanied by a loss of elasticity, it comes to a dilatation of the wall. The formed dilatation presents
an increased wall tension relative to the intraaortic pressure, which promotes the progression of the dilatation. With
progression in diameter aortic aneurysms are associated with a high risk of dissection and rupture. There are many factors that contribute to the development of an aneurysm. The congenital syndromes associated most with this condition
are Marfan’s syndrome, Ehlers Danlos syndrome, or Loeys–Dietz syndrome [2]. Certain families, without phenotypic
expression of the above named syndromes, present with a history of ascending aortic aneurysm formation and dissection, transmitted in an autosomal dominant fashion [3,4]. Other factors include degenerative diseases (e.g., cystic medial
degeneration, atherosclerosis), inflammatory diseases (e.g., Takayasu arteritis, Behçet disease, Kawasaki disease, giant
cell arteritis, ankylosing spondylitis), or infectious diseases [1]. An aneurysm could develop in time after a blunt or
penetrating trauma to the chest, involving the aorta, or after previous cardiac surgery at the site of aorta-to-aorta or aortato-graft anastomoses [5].
The most common risk factors are hypertension, atherosclerosis, smoking, and the genetic disorders such as Marfan’s
and Ehlers–Danlos syndromes.
The cystic medial degeneration is the most common histological etiology of ascending thoracic aortic aneurysm
disease [6].
New Approaches to Aortic Diseases from Valve to Abdominal Bifurcation. http://dx.doi.org/10.1016/B978-0-12-809979-7.00046-8
Copyright © 2018 Elsevier Inc. All rights reserved.
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There are two different entities, true and false aortic aneurysms. A true aortic aneurysm is a permanent localized dilatation of the aorta, with 50% or greater than normal diameter, contained by walls that have all layers of the normal wall [7],
while by a false aortic aneurysm or pseudoaneurysm the walls do not contain all the layers of the arterial wall.
By definition, an ascending aortic aneurysm is located between the aortic valve and the origin of the arterial brachiocephalic trunk. We refer to an aortic arch aneurysm when the dilated portion of the aorta is located between the origin of
the arterial brachiocephalic trunk on the one part, and, of the left subclavian artery on the other part. An aneurysm of the
descending aorta is defined as a disease extending below the latter.
INDICATIONS FOR SURGICAL TREATMENT
In the past 20 years as a result to the continuous pursuit of reducing the surgical trauma and the degree of surgical invasiveness, the treatment options for aortic disease have significantly expanded.
When confronted with a thoracic and/or abdominal aortic aneurysm, the aim of surgery is the avoidance of rupture,
rarely of compression on the adjacent organs.
Symptoms of impending rupture or a life-threatening compression of the intrathoracic organs require an urgent treatment [8,9] (Fig. 46.1).
The above-presented indications for surgery are cited from the “2014 ESC Guidelines on the diagnosis and treatment of
aortic diseases” and have been proven only with a C level of evidence.
“Lower thresholds can be used for combining surgery on the ascending aorta for patients who have an indication for
surgery on the aortic valve” [10].
SURGICAL APPROACH AND SURGICAL TECHNIQUE
According to the Society of Thoracic Surgeons (STS) database from 2003, a minimally invasive cardiac surgery is defined
as “any procedure not performed with a full sternotomy and cardiopulmonary bypass support” [11]. In 2008, the American
Heart Association revised this definition as “a small chest incision that does not include the conventional full sternotomy”
[12]. Referring to this definition in our department we focus our attention on minimally invasive techniques in all aspects
of cardiac surgery, aiming to reduce the degree of surgical invasiveness [13].
Current minimally invasive approaches to the aortic valve are the upper partial sternotomy (e.g., “J-shaped”), the right
parasternal thoracotomy, and the lower partial sternotomy.
Standard Approach in Our Institution for Thoracic Aneurysm Surgery
The patients are anesthetized in a supine position and are intubated with a single-lumen endotracheal tube. Defibrillator
pads are placed over the left lateral chest wall and on the back of the patient, above the right scapula.
TAA
Isolated AoAr
≥ 55 mm
IIb
Marfan
AAo/AoR
Other
FIGURE 46.1 Recommendations on surgical interventions on ascending aortic aneurysms. AAo, ascending aorta, AoR, aortic rot, AoAr, aortic arch,
BAV , bicuspid aortic valve.
AoR
≥ 50 mm
I IIa IIa IIa
AAo/AoR
≥ 45 mm
BAV &
AAo/AoR
≥ 50 mm
Other
≥ 55 mm
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Through a 5- to 7-cm skin incision, having the sternal angulus approximately in the mid-portion, the third or fourth
intercostal space (IS) is exposed [14]. The sternum is then opened with an oscillating saw at the midline from the jugular
groove down to the exposed IS [13]. The right internal mammary artery is spared. The remnant thymus is longitudinally
dissected, the brachiocephalic vein is mobilized, and the pericardial sack is opened in an “H” shape. Mostly, this technique
allows for approach to the thoracic aorta from root to arch. In cases of arch surgery, the arterial brachiocephalic trunk is
also easily exposable above or below the brachiocephalic vein. There are different strategies for arch surgery by means of
establishing the antegrade cerebral perfusion (Fig. 46.2).
After placing the stay sutures and inspecting the aorta, the proper cannulation site is defined. When cannulating the
distal ascending aorta or the proximal aortic arch, the assistant with a clamp pulls gently the aorta inferiorly and to the
right and with the other hand retracts the brachiocephalic vein with a hook for an optimal exposition. In selected cases, the
Seldinger technique is used for aortic cannulation (Fig. 46.3).
Right axillary cannulation is used for cases with severe aortic calcification or to those who need aortic arch reconstruc-
tive surgery [15]. The axillary artery can be cannulated directly or using a Dacron side graft.
In patients presenting with large aneurysms often accompanied by elongation of the aorta, the heart is shifted inferiorly
and to the left, making the access to the right atrial appendage difficult. In these cases, we perform a percutaneous femoral
venous cannulation using the Seldinger technique. Otherwise, we use a flat two-stage cannula inserted through a separate
subxyphoidal skin incision, pulled up retrosternally and prepericardially and put in place via the right atrial appendage,
while the assistant holds the aneurysm gently aside [13].
For venting, an appropriate catheter is placed via the right superior pulmonary vein and the mitral valve or, for patients
with difficult access, directly in the main pulmonary artery (Fig. 46.4).
After cross-clamping the aorta, the cardioplegic solution is being administered into the aortic roots in those without severe aortic regurgitation. In all other cases, the myocardial protection solution, Bretschneider HTK (Custodiol,
Köhler-Chemie, Ansbach, Germany) is being applied selectively in the coronary ostia. The opening of the ascending
aorta and the operative technique used are then chosen in relation to the pathology in the present case. If circulatory
arrest is required, a moderate hypothermia, 28–32°C, is induced. The selective antegrade cerebral perfusion is established either through the right axillary arterial cannula accompanied by a selective cannulation of the left common
carotid artery or a selective cannulation of both common carotid arteries.
axillary
Arch surgery
Arterial
cannulation
Ascending
aortic surgery
FIGURE 46.2 Arterial cannulation strategies.
FIGURE 46.3 Operative sites presenting an aneurysm of the ascending aorta. AAo, ascending aorta, RAapp, right atrial appendage.
Direct aortic
arch
femoral
Direct aortic
arch
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FIGURE 46.4 Operative sites presenting incision size and cannulas in place after upper partial sternotomy. AC, arterial cannula, VC, venous cannula.
1.
2.
3.
4.
wires
FIGURE 46.5 Representation of closed chest, placed pacing wires, and drain tube at the end of a surgery performed using an upper partial sternotomy.
The further conduct of the surgery follows the standards for the purposed procedure.
To minimize the risk of air embolism, the operative field is flooded with carbon dioxide. Before opening the aortic
clamp, a ventricular pacing wire is being placed at the level of the right ventricular outflow tract. Thereafter, deairing subtle
maneuvers are undertaken. Ultimately, for declamping, the patient’s body position is changed into Trendelenburg position
to avoid any remaining air bubbles being ejected into the cerebral circulation. After adequate rewarming and reperfusion,
the patient is decannulated. A standard chest tube is being placed through the subxyphoidal incision used for the venous
cannula. In case of femoral venous cannulation, the placing of chest tube is similar to the central venous cannulation
through a subxyphoidal incision (Fig. 46.5).
The sternum, the subcutaneous layers, and the skin are closed in the same fashion used by full sternotomy approach.
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Transesophageal echocardiography (TEE) is used throughout the surgery. At the beginning of the surgery, the TEE is
used as guidance either for the aortic or for percutaneous transfemoral venous cannulation via Seldinger’s technique. At
the end of surgery, the TEE can monitor the deairing process, as well as check the valve function or the existence of any
paravalvular leakage, if a concomitant procedure on the aortic valve has been conducted [16].
Surgical Technique According to Pathology
If the aortic root and the ascending aorta present an aneurysmal dilatation, then the entire proximal aorta including the
aortic valve needs to be part of the operational planning [17,18].
In the case of a supracommissural located fusiform aneurysm, the dilated aortic section is resected and a supracommissural aortic replacement with a vascular graft is performed [19]. In cases of proximal aortic disease with a significantly
degenerated and stenotic aortic valve, a replacement of the aortic valve and diseased portion of the aortic root and ascending
aorta with a composite conduit or tissue root prosthesis is the standard therapy [20–22]. For patients with aortic valve regurgitation and root dilatation, valve sparing root reconstructive techniques are recommended [23–26]. Valve sparing aortic
root replacement operations, using the reimplantation technique of the aortic valve, have already demonstrated excellent
results at up to 15 years of follow-up [20]. Patients receiving this procedure have showed improved quality of life, without
the necessity for anticoagulation therapy, and higher exercise capacity when compared with patients operated on using a
composite conduit [27]. Depending on the extent of the aneurysmal disease, when involving the arch, the above-mentioned
approaches are applied in combination with hemiarch or total transverse aortic arch replacement using an elephant trunk
procedure, either conventional or frozen.
RESULTS AND DISCUSSION
In our institution, the minimally invasive approach has become the standard for aortic diseases [13]. Currently, via the
J-shaped upper partial sternotomy we perform all kinds of aortic valve and additional procedures on the thoracic aorta in a
routine fashion, including even a few cases of complete arch replacement with frozen elephant trunk (Figs. 46.6 and 46.7).
The colleagues from the Cleveland Clinic, USA, report over similar data and the same extended spectrum of aortic
surgical procedures being routinely performed using an upper partial sternotomy [15].
The minimal invasive access via upper partial sternotomy is associated with better chest and sternal stability, better
conservation of the lung function [28,29], shorter hospital stay and faster recovery, less postoperative pain in addition to an
improved cosmetic result [13], and does not result in an increased surgical risk [14]. By using this approach, only a limited
portion of the heart is exposed, less adhesions of the heart are probable to be produced than with a full sternotomy approach,
making a second heart surgery less risky.
100
90
80
70
60
50
40
30
20
10
0
2008 2009 2010 2011 2012 2013 2014 2015
2007
DAVID AAR ROSS DAVID+AArchR AAR+AArchR
FIGURE 46.6 Isolated thoracic aortic aneurysm patients operated in our department using a full sternotomy. AAR + AArchR, ascending aorta combined
with aortic arch replacement; AAR, ascending aortic replacement; DAVID + AArchR, David procedure combined with aortic arch replacement; DAVID,
David procedure; ROSS, Ross procedure.
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100
90
80
70
60
50
40
30
20
10
0
2007 2008
DAVID AAR ROSS DAVID+AArchR AAR+AArchR
FIGURE 46.7 Isolated thoracic aortic aneurysm patients operated in our department using an upper partial sternotomy. AAR + AArchR, ascending aorta
combined with aortic arch replacement; AAR, ascending aortic replacement; DAVID + AArchR, David procedure combined with aortic arch replacement;
DAVID, David procedure; ROSS, Ross procedure.
2009 2010 2011 2012 2013 2014 2015
FIGURE 46.8 Intraoperative image of minimally invasive David procedure with additional cusp repair. AC, arterial cannula; LMCA, left main coronary
artery; Plic, cusp plication.
In 2016, we published excellent 5-year follow-up results on 117 patients who received a David procedure via an upper
partial sternotomy [30], whereas a quality of life survey conducted on patients after Ross procedure detected better physical parameters and a higher satisfaction with the cosmetic result when using a minimally invasive access [13] (Fig. 46.8).
Johnston et al. report also on benefits in favor of partial sternotomy with improved patient perception of quality of life
and posthospital outcomes such as return to work and functional capacity [15].
A number of authors report on a large series of patients with excellent morbidity and mortality outcomes when using
this access strategy for aortic valve replacement procedures [15,28,29,31,32].
This specific minimally invasive approach is technically very demanding. Pioneers in this field are Svensson and
D’Agostino with their first reports in 1998 [33]. Other working groups such as Byrne et al. [34], and continuing with Tabata
et al. [35], and Kaneko et al. [36] followed them. They all reported encouraging results for this challenging approach, proving its feasibility.
In 2001, Svensson et al. showed that minimal access aortic surgery including reoperations can be achieved safely and
has positive effects on postoperative recovery [37].
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Deschka et al. present their positive experience with aortic pathologies using an “L”-shaped upper partial sternotomy (from the sternal notch to the left fourth IS) on 50 consecutive patients [38]. Additionally, Totaro et al. described
a safe and feasible minimally invasive approach using an upper partial sternotomy in the shape of a “reversed T”
performed in 1126 patients receiving complex cardiac procedures [39].
After conducting a meta-analysis regarding the ministernotomy approach for aortic root and ascending aorta surgery,
Perrotta and Lentini conclude that the “T”- or “J”-shaped upper partial sternotomy is a feasible alternative to the full sternotomy and could be more extensively used in the future [40].
Reviewing the different possible approaches presented, the most reported on are the upper partial sternotomy, the
right parasternal approach, and the lower partial sternotomy. The parasternal approach involves the resection of the
second and third costal cartilage, sacrificing the right internal mammary artery [41,42] and does not offer the possibility to treat any other concomitant disease of the thoracic aorta. A lower partial sternotomy can be performed when
facing a low positioned aorta within the chest [15,43], which does not apply to the majority of the patients. In our
experience, the upper partial sternotomy from all presented minimally invasive approaches offers the best exposition
when encountering different thoracic aorta pathologies.
CONCLUSION
Patients do not want a full sternotomy when it can be avoided. If a safe, effective, and reproducible minimally invasive
surgery can be provided [15], then patients are more likely to consent to the operation.
Careful patient selection, preoperative imaging, and when necessary conversion to full sternotomy are important factors
when developing a minimally invasive surgery program. With increased experience, a wide range of concomitant procedures can be safely performed in a large number of patients with equal surgical results, improved cosmesis, and improved
patient perception of quality of life.
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[8] Coady MA, Rizzo JA, Elefteriades JA. Developing surgical intervention criteria for thoracic aortic aneurysms. Cardiol Clin 1999;17:827.
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[10] Erbel R, Aboyans V, Boileau C, Bossone E, Di Bartolomeo R, Eggebrecht H, et al. 2014 ESC Guidelines on the diagnosis and treatment of aortic
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