How to Deal With Graft Kinking in Ascending Aortic Surgery

Ascending aortic graft kinking occurs incidentally after replacement of the ascending aorta. If not corrected, graft kinking may cause heart failure (1), severe hemolytic anemia with renal dysfunction (2), or graft thrombosis and thromboembolism (3). All these complications require redo surgery to replace the kinked graft.

The reason for aortic graft kinking is excessive graft length. To prevent graft kinking, one should measure the graft length and size appropriately before completing the last aortic anastomosis. Though it sounds easy, it is sometimes challenging, as measurements and anastomoses are performed on an empty heart, and after declamping and filling the heart, the relationships of the graft to the heart and the aortic arch may change, causing graft kinking. Shortening of the graft may be needed at this stage.

The most conservative approach is to reclamp the aorta and resect the graft under repeat cardioplegia. A more complicated approach is to apply two clamps above and beneath the kinking and perform resection on a beating heart under selective root perfusion with warm oxygenated blood. However, there is a nonclamping technique for graft kinking that was first described 20 years ago (4). This very simple but extremely effective technique is not widely known, so the authors have decided to share it in this video using a simulation model.

References

1. Numaguchi K, Hatake S, Ueda T, Tomita Y. A kinked aortic tube graft after aortic root replacement causes heart failure: usefulness of the right parasternal approach on echocardiography. J Med Ultrason. 2015;42(2):291-292.
2. Kitahara H, Yoshitake A, Hachiya T, Okamoto K, Kawaguchi S, Shimizu H. Kinked graft and anastomotic stenosis-induced hemolytic anemia requiring reoperation. Ann Vasc Surg. 2016;30:308.e1-308.e4.
3. Wahba A, Ødegård A, Skjetne K, Dalen H. Late thrombosis of a kinked ascending aortic graft. Eur J Cardiothorac Surg. 2014;46(1):140.
4. Zattera GF, Actis Dato GM, Del Ponte S, Poletti GA. A simple method to correct aortic tube graft kinking without cardiopulmonary by-pass and aortic clamping. Eur J Cardiothorac Surg. 2000;18(5):611-612.