Con: “Debate: does every ascending aorta repair require at least an open distal anastomosis at the innominate? Or not?”
Viewpoint on Cardiac Surgery

Con: “Debate: does every ascending aorta repair require at least an open distal anastomosis at the innominate? Or not?”

Kenji Minatoya

Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan

Correspondence to: Kenji Minatoya, MD, PhD. Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan. Email:

Received: 21 November 2017; Accepted: 09 February 2018; Published: 13 March 2018.

doi: 10.21037/jovs.2018.02.05

Ascending aortic replacement is usually performed with a cross-clamp at the distal ascending aorta. This cross-clamping is one of the routine procedures in cardiac surgery, and the risk of the cross-clamping has been lowered to minimum in regular practice. Theoretically, the cross-clamp itself is a risk to apply and might lead to aortic dissection (1) or create a source of embolization in the aortic wall. However, when there is no atheroma, calcification, or other abnormal situations including aortic dissection in the aorta, the cross-clamp is applied very safely in modern cardiac surgery.

The distal anastomosis of the ascending aortic replacement is made on the aorta just proximal to the cross-clamp. In fact, the length of the replacement is actually shortened to allow for the width of the cross-clamp and seam. Although not wide, this area of the native aorta is not replaced. The region of the cross-clamp could be damaged and in the long run might lead to some new lesion at that site. Anastomosis with a graft adjacent to the cross-clamp is sometimes difficult, especially when the room allowed for the seam is minimal. On the contrary, the ascending aorta is known to be embryologically different from the aortic arch (2,3). The remnant of the diseased ascending aorta could dilate afterwards when ascending aortic replacement is undergone with a cross-clamp. Consequently, it is natural to consider that the diseased ascending aorta should be completely replaced.

The aortic return of a cardiopulmonary bypass is preferentially placed at the ascending aorta for antegrade perfusion. In itself, placement of the aortic return carries the same risk as that of the cross-clamp. Arch cannulation or peripheral cannulation, such as of the femoral and axillary arteries, requires more radical resection of the ascending aorta. The cannulation site at the ascending aorta could raise some problems including pseudoaneurysm and bleeding in the follow-up periods.

When ascending aortic replacement is performed with open proximal anastomosis, the place of the cross-clamp and the cannulation at the ascending aorta could be resected. Anastomosis is technically easy; no tension exists during anastomosis with the open proximal technique. From this point of view, open distal anastomosis can only be good for ascending aortic replacement. Two decades ago, King et al. reported that open distal anastomosis with hypothermic circulatory arrest does not increase the risk of ascending aortic replacement (4). However, whenever the open proximal anastomosis is utilized, body temperature needs to be lowered. Additional cerebral protection could alleviate the burden of hypothermia, but a longer pump time is mandatory to control the body temperature. In the end, open distal anastomosis cannot be considered a low-risk procedure for any patient.

Marfan syndrome (MFS) is known to come with numerous aortic complications in the patients’ lifetime. Once patients with MFS have acute aortic dissection, the aorta becomes continuously dilated. Therefore, prophylactic root replacement is recommended to protect from the onset of dissection. Personally, I employ open distal anastomosis in younger patients with MFS. The site of the cross-clamp in patients with MFS could be a reason for dissection, which should be avoided at all costs. In practice, among these cases, open proximal anastomosis is not always utilized at the time of root replacement (5,6).

Two decades ago several studies shed light on the aortopathy of the ascending aorta related to the bicuspid aortic valve (BAV). The tissue pathology of BAV is not limited to the valves’ leaflets, but extends from the left-ventricular outflow tract to the ascending aorta. De Sa et al. reported that compared to patients with tricuspid aortic valve disease, those with BAV disease have more severe degenerative changes in the media of the ascending aorta (7). Russo et al. recommended the prophylactic replacement of even a seemingly normal and definitely of a mildly enlarged ascending aorta in cases of BAV when aortic valve replacement is done (8). Borger et al. also performed aggressive replacement of the ascending aorta in patients with BAV (9). These studies suggested prophylactic aggressive replacement of the ascending aorta due to the inherited nature of the aortopathy related to BAV. Similarly, Fazel et al. concluded that aortopathy with BAV usually involves the transverse arch (10). These reports mentioned cystic medial necrosis as an abnormal histopathology of BAV, which renders it close to the histopathology of MFS. When performing complete resection of the ascending aorta, open distal anastomosis is theoretically better, as previously mentioned. However, recent studies presented rebutting evidence (11-15). The inherited nature of the aorta in patients with BAV appears to be less serious than the nature of the aorta with MFS. Park et al. reported that progressive dilatation of the aortic arch, leading to reoperation after repair of an ascending aortic aneurysm, is uncommon in patients with a BAV (16). Additionally, aortic valve surgery could change the risk of the aortopathy in patients with BAV (17).

I think that in patients with acute aortic dissection, open proximal anastomosis is essential. Although the cross-clamp could be applied during surgery, the cross-clamp might cause new tears and increase the risk of new malperfusion (18). Lawton et al. reported that a strategy without cross-clamp for the treatment of acute type A aortic dissection was associated with a highly significant improvement in survival (19).

In conclusion, open distal anastomosis is not always required for every ascending aortic repair except cases of acute aortic dissection. Open distal anastomosis is an excellent strategy; however, in each case, application of this technique should depend on the balance between risk and benefit.




Conflicts of Interest: The author has no conflicts of interest to declare.


  1. Leontyev S, Borger MA, Legare JF, et al. Iatrogenic type A aortic dissection during cardiac procedures: early and late outcome in 48 patients. Eur J Cardiothorac Surg 2012;41:641-6. [Crossref] [PubMed]
  2. Pfaltzgraff ER, Shelton EL, Galindo CL, et al. Embryonic domains of the aorta derived from diverse origins exhibit distinct properties that converge into a common phenotype in the adult. J Mol Cell Cardiol 2014;69:88-96. [Crossref] [PubMed]
  3. Kau T, Sinzig M, Gasser J, et al. Aortic development and anomalies. Semin Intervent Radiol 2007;24:141-52. [Crossref] [PubMed]
  4. King RC, Kron IL, Kanithanon RC, et al. Hypothermic circulatory arrest does not increase the risk of ascending thoracic aortic aneurysm resection. Ann Surg 1998;227:702-5. [Crossref] [PubMed]
  5. Price J, Magruder JT, Young A, et al. Long-term outcomes of aortic root operations for Marfan syndrome: A comparison of Bentall versus aortic valve-sparing procedures. J Thorac Cardiovasc Surg 2016;151:330-6. [Crossref] [PubMed]
  6. Attenhofer Jost CH, Connolly HM, Scott CG, et al. Aortic Root Surgery in Marfan Syndrome: Medium-Term Outcome in a Single-Center Experience. J Heart Valve Dis 2017;26:45-53. [PubMed]
  7. de Sa M, Moshkovitz Y, Butany J, et al. Histologic abnormalities of the ascending aorta and pulmonary trunk in patients with bicuspid aortic valve disease: clinical relevance to the ross procedure. J Thorac Cardiovasc Surg 1999;118:588-94. [Crossref] [PubMed]
  8. Russo CF, Mazzetti S, Garatti A, et al. Aortic complications after bicuspid aortic valve replacement: long-term results. Ann Thorac Surg 2002;74:S1773-6; discussion S1792-9.
  9. Borger MA, Preston M, Ivanov J, et al. Should the ascending aorta be replaced more frequently in patients with bicuspid aortic valve disease? J Thorac Cardiovasc Surg 2004;128:677-83. [Crossref] [PubMed]
  10. Fazel SS, Mallidi HR, Lee RS, et al. The aortopathy of bicuspid aortic valve disease has distinctive patterns and usually involves the transverse aortic arch. J Thorac Cardiovasc Surg 2008;135:901-7,907.e1-2.
  11. McKellar SH, Michelena HI, Li Z, et al. Long-term risk of aortic events following aortic valve replacement in patients with bicuspid aortic valves. Am J Cardiol 2010;106:1626-33. [Crossref] [PubMed]
  12. Andrus BW, O'Rourke DJ, Dacey LJ, et al. Stability of ascending aortic dilatation following aortic valve replacement. Circulation 2003;108 Suppl 1:II295-9. [Crossref] [PubMed]
  13. Girdauskas E, Disha K, Raisin HH, et al. Risk of late aortic events after an isolated aortic valve replacement for bicuspid aortic valve stenosis with concomitant ascending aortic dilation. Eur J Cardiothorac Surg 2012;42:832-7. [Crossref] [PubMed]
  14. Gaudino M, Anselmi A, Morelli M, et al. Aortic expansion rate in patients with dilated post-stenotic ascending aorta submitted only to aortic valve replacement long-term follow-up. J Am Coll Cardiol 2011;58:581-4. [Crossref] [PubMed]
  15. Disha K, Rouman M, Secknus MA, et al. Are normal-sized ascending aortas at risk of late aortic events after aortic valve replacement for bicuspid aortic valve disease? Interact Cardiovasc Thorac Surg 2016;22:465-71. [Crossref] [PubMed]
  16. Park CB, Greason KL, Suri RM, et al. Should the proximal arch be routinely replaced in patients with bicuspid aortic valve disease and ascending aortic aneurysm? J Thorac Cardiovasc Surg 2011;142:602-7. [Crossref] [PubMed]
  17. Kim YG, Sun BJ, Park GM, et al. Aortopathy and bicuspid aortic valve: haemodynamic burden is main contributor to aortic dilatation. Heart 2012;98:1822-7. [Crossref] [PubMed]
  18. Malvindi PG, Modi A, Miskolczi S, et al. Open and closed distal anastomosis for acute type A aortic dissection repair. Interact Cardiovasc Thorac Surg 2016;22:776-83. [Crossref] [PubMed]
  19. Lawton JS, Liu J, Kulshrestha K, et al. The impact of surgical strategy on survival after repair of type A aortic dissection. J Thorac Cardiovasc Surg 2015;150:294-301.e1. [Crossref] [PubMed]
doi: 10.21037/jovs.2018.02.05
Cite this article as: Minatoya K. Con: “Debate: does every ascending aorta repair require at least an open distal anastomosis at the innominate? Or not?”. J Vis Surg 2018;4:49.