Midterm experience with modified Cabrol procedure: Safe and durable for complex aortic root replacement

Abstract

The modified Cabrol technique using a Dacron interposition graft showed good survival rates and excellent durability over time, confirmed radiographically. These data confirm that it is appropriate to use the Cabrol technique when technical complexity prevents bringing coronary buttons to the main aortic graft.

Aortic Root Reconstruction with a New Dacron Graft Featuring Prefabricated Coronary Side Branches

“…In a recent report of their midterm experience with a modified Cabrol procedure, Elefteriades and colThe use of this graft simplifies coronary reattachment, minimizing the need for coronary mobilization, and also facilitates the anastomotic technique. This is in accordance with our experience with total arch and thoracoabdominal aortic replacement, in which the routine use of multibranched prosthetic grafts allows direct anastomosis to the leagues report the use of a variation of the Cabrol reconstruction in a non-negligible 11.5% of their root replacements, indicating that the challenge of coronary button preparation and reimplantation can be significant [13]. Accordingly, previous reports in the literature of numerous modifications of the coronary reimplantation technique aimed at preventing complications with coronary perfusion reiterate the significance of this problem.…”

“…There was no evidence of coronary flow obstruction or formation of anastomotic pseudoaneurysms ( Figure 5). This latter complication is most likely related to the use of the "inclusion" technique that is traditionally adopted with the Cabrol reconstruction [13,19], but it may also be related to the fact that these patients have been subject to postoperative anticoagulation to lower the risk of Cabrol graft thrombosis. By virtue of preserving the physiology of coronary circulation, which prevents the unbalanced coronary flow distribution within the Cabrol graft, none of our patients required any perioperative anticoagulation treatment, and only long-term aspirin therapy was administered.…”

“…The occurrence of ventricular dysfunction, perioperative myocardial infarction, or surgical bleeding depends on the technical difficulty of coronary reimplantations [3-5, 11, 13]. Damage to the coronary buttons during mobilization and tension or kinking after completion of the anastomosis can cause coronary malperfusion [3,4,[13][14][15]. These mechanisms are illustrated in detail by Elefteriades' group in their report describing "rescue coronary artery bypass grafting" to treat acute coronary insufficiency after ARR ( Figure 2) [4,16].…”

“…These mechanisms are illustrated in detail by Elefteriades' group in their report describing "rescue coronary artery bypass grafting" to treat acute coronary insufficiency after ARR ( Figure 2) [4,16]. These challenges can be more difficult in redo operations or for porcelain aortas in which the presence of scar tissue and aortic calcification obstructs mobilization of the coronaries [13,17,18]. Similarly, in valve-sparing reconstructions, the presence of aortic valve leaflets re-implanted into the prosthetic graft may require more extensive coronary mobilization to find the appropriate re-attachment location on the Dacron graft.…”

“…For instance, Westaby and colleagues propose a technique using a "pericardial hood" extension added to the right coronary anastomosis ( Figure 3A) [14] to avoid kinking or tension, whereas others advocate the use of a coronary vein bypass interposed between the main aortic graft and the right coronary button [2]. The Cabrol reconstruction represents a more radical approach to the problem [19] and is meant to obviate the challenges of coronary reimplantation when mobilization of the coronaries is cumbersome [2,13,[17][18][19]. Nevertheless, this technique may be associated with a higher rate of mortality and morbidity compared with modified Bentall reconstruction.…”