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Cobrahead-style Grafting for Intercostal Artery Attachment in Descending Thoracic Aortic Replacement

Shawn L. Tittle, Desoram Teso, Maryanne Tranquilli, Richard K. Shaw, Gary S. Kopf, John A. Elefteriades
Yale University School of Medicine, New Haven, CT

The predominant method for attachment of intercostals arteries in thoracic aortic replacement is side-to-side anastomosis to the main aortic graft. This technique has two inherent problems: the anastomosis is difficult to expose or control in case of bleeding; also, the incorporated aortic wall may later become aneurysmal. To obviate these issues, we employ a side-arm graft with an on-lay end-to-side “cobrahead” style anastamosis over the included spinal arteries.
We retrospectively reviewed the charts of 17 patients who underwent cobrahead-style grafting at our institution between 1999 and 2003 as part of operations on the descending aorta in 7 patients and the thoracoabdominal aorta in 10 patients. Fifteen operations were for aneurysm and 2 for dissection. Operations were performed under left atrial to femoral artery bypass. In patients felt to be at high risk for paraplegia, the cobrahead graft is constructed first and perfused from the arterial line, before construction of the main graft.
Main Outcome Measure/Results:
Seventeen patients underwent cobrahead-style grafting. Freedom from paraplegia was 17/17 (100%). One patient experienced transient left lower extremity weakness that resolved prior to hospital discharge. One patient required re-exploration for bleeding from the cobrahead anastamosis, which was easily exposed and controlled. Survival was 16/17 (94%), with the only death due to intraoperative retrograde dissection to the ascending aorta.
The cobrahead technique is safe and effective for prevention of paraplegia in descending aortic surgery. Advantages include ease of access and exclusion of diseased aorta (neighboring the intercostal orifices) from the main aortic lumen.

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