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• W3194747415 abstract "Although median sternotomy is the most widely used approach for aortic arch repair, the extent of arch replacement via this incision can be limited. Bilateral thoracosternotomy (clamshell incision) represents an alternative approach that allows for replacement of the entire aortic arch with or without the descending thoracic aorta in a single procedure. Given our extensive institutional experience with bilateral thoracosternotomy for orthotopic lung transplantation, we began using this approach for select complex arch repairs in 2005. For the present study, all 16 patients who had undergone bilateral thoracosternotomy for aortic arch surgery from 2005 to 2020 were identified from our prospectively maintained institutional aortic surgery database. The patients (n = 81) who had undergone median sternotomy for total arch replacement during the same period were identified as a comparison group. The primary outcomes included 30-day/in-hospital mortality, stroke, spinal cord ischemia, new dialysis, prolonged (>24-hour) ventilator support, and wound complications. Descriptive statistics and Student's t test were used. Patient characteristics and outcomes are presented in the Table. Bilateral thoracosternotomy was most often used (75% of cases) for total arch replacement, including the distal arch and some segment of the descending thoracic aorta. In the remaining 25%, it was used for complex coarctation repair. Compared with the patients undergoing total arch replacement via median sternotomy, the thoracosternotomy group was significantly younger (median age, 42 vs 55 years; P < .001) with a similar rate of prior cardiac surgery (56% vs 48%; P = .55). No difference was found in the 30-day or in-hospital rates of death, stroke, spinal cord ischemia, new dialysis, or prolonged ventilation between the thoracosternotomy and median sternotomy groups. The thoracosternotomy group did have a significantly greater rate of wound complications requiring surgical debridement (12% vs 0%; P = .001). Both groups had similar excellent 1-year survival (94% thoracosternotomy vs 82% sternotomy; P = .26). Bilateral thoracosternotomy represents an excellent and underused approach for select complex arch repairs, especially in the setting of a “mega aorta” or pathology involving the mid- to distal arch into the descending thoracic aorta. The technique yields similar results to a median sternotomy-based approach and avoids the need for two-stage repair.TablePatient characteristics and outcomesCharacteristicBilateral thoracosternotomy (N = 16)Median sternotomy for total arch replacement (N = 81)P valueAge, years42 (13-74)55 (24-81)<.001Male sex55 (68)11 (69).95Arch operation Pediatric repair of coarctation3 (19)0 (0) Total arch replacement12 (75)81 (100) Hemi-arch + ascending–descending aortic bypass for adult coarctation1 (6)0 (0)Prior sternotomy9 (56)39 (48).5530-day/in-hospital mortality1 (6)6 (7).8730-day/in-hospital morbidity Stroke1 (6)2 (3).47 Permanent paraparesis/paraplegia0 (0)0 (0).52 New dialysis0 (0)5 (7).31 Ventilator support >24 hours4 (27)16 (21).63 Wound infection requiring surgical debridement2 (12)0 (0).001Survival at 1 year15 (94)66 (82).26Data presented as median (range) or number (%). Open table in a new tab" @default.
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• W3194747415 date "2021-09-01" @default.
• W3194747415 modified "2023-09-26" @default.
• W3194747415 title "Bilateral Thoracosternotomy (Clamshell Approach) for Complex Aortic Arch Surgery" @default.
• W3194747415 doi "https://doi.org/10.1016/j.jvs.2021.06.187" @default.
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