Clamshell thoracosternotomy for single-stage repair of select aortic arch pathologies

Although median sternotomy is widely used for aortic arch repair, the distal extent of arch replacement is limited with this approach. Bilateral thoracosternotomy (clamshell) represents an alternate and underappreciated strategy that allows for single-stage repair of the aortic arch and descending thoracic aorta. We report our institutional experience with this approach.

Patients who underwent clamshell thoracosternotomy for aortic arch surgery from 2005 to 2022 were identified from a prospectively maintained institutional aortic surgery database. The primary outcomes were 30-day/in-hospital mortality and major morbidity, including stroke, paraplegia, and renal failure requiring hemodialysis. Secondary outcomes included late overall survival, aorta-specific survival, and freedom from aortic reintervention.

Clamshell thoracosternotomy was performed in 18 patients (67% men) with median age 52 years; 50% (n = 9) had heritable thoracic aortic disease. Clamshell repair indications included focal arch dissection (44%; n = 8), extensive arch aneurysm or pseudoaneurysm (33%; n = 6), complex pediatric coarctation (17%; n = 3), and adult coarctation with ascending aneurysm (6%; n = 1). Operative mortality occurred in 1 patient (6%). No patients developed stroke, paraplegia, or renal failure. Overall actuarial survival was 94% at 1 year and 72% at 5 years, whereas aorta-specific survival was 94% at 1 and 5 years. There were no reinterventions on the contiguous aorta at a median follow-up of 60 months (range, 18-85 months).

Clamshell thoracosternotomy is a safe approach for single-stage complex open arch with or without descending repair, especially for those with heritable thoracic aortic disease or anatomy not amenable to endovascular therapies.