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J Thorac Cardiovasc Surg 2002;123:1006-1008
© 2002 The American Association for Thoracic Surgery

Brief Communications

Aortic balloon occlusion catheter with perfusion lumen for protection of lower body during distal anastomosis in aortic arch repair

From the First Department of Surgery, Gifu University School of Medicine, Gifu, Japan.

Received for publication Nov 29, 2001. Accepted for publication Dec 9, 2001. Address for reprints: Hisato Takagi, MD, PhD, First Department of Surgery, Gifu University School of Medicine, 40 Tsukasa, Gifu 500-8705, Japan (E-mail: h-takagi{at}cc.gifu-u.ac.jp).

We have developed an original aortic balloon occlusion catheter with a perfusion lumen (Figure 1) ¹ to perfuse the lower half of the body antegradely during distal anastomosis in aortic arch repair and have applied it in several cases. The purpose of the present article is analyzing our experiences of a technique with the catheter.

View larger version (25K): [in this window] [in a new window]   Fig. 1. A 21F aortic balloon occlusion catheter with a 14F perfusion lumen (MD-21020; Sumitomo Bakelite, Tokyo, Japan).

Eight patients underwent aortic arch repair with an aortic balloon occlusion catheter with a perfusion lumen (Figure 1) for protection of the lower half of the body during distal anastomosis. Patients' characteristics are shown in Table 1. The reasons to avoid perfusion through the femoral artery were the following: (1) coexistence of abdominal aortic aneurysm in 4 patients; (2) concomitant atherosclerosis obliterans (stenosis or occlusion of the iliac artery) in 2 patients; and (3) clinical trial in 2 patients. All aneurysms were repaired through only a median sternotomy. Cardiopulmonary bypass was established by cannulating the ascending aorta in principle. In one case with Stanford type A acute aortic dissection, a prosthetic graft anastomosed to the right axillary artery was used for systemic perfusion. When rectal temperature reached approximately 25°C by means of core cooling, both the brachiocephalic and the left common carotid arteries were cannulated to establish selective cerebral perfusion. Soon after systemic perfusion was discontinued, the aortic arch was incised and mural thrombi were removed, carefully avoiding their fall into the descending thoracic aorta. An aortic balloon occlusion catheter with a perfusion lumen was next inserted into the descending thoracic aorta, and its balloon was inflated. The catheter was fixed on the chest wall so as not to disturb distal anastomosis. Thereafter, antegrade perfusion of the lower half of the body was initiated through the catheter, and distal anastomosis was performed. After repair of the aortic arch aneurysm, systemic perfusion was restarted through a replaced graft or the originally placed cannula.

Antegrade perfusion duration of the lower half of the body during distal anastomosis by using an aortic balloon occlusion catheter with a perfusion lumen was 30.1 ± 16.9 minutes. The flow rate was 32.9 ± 7.5 mL · min^-1 · kg^-1, the pressure of the lower extremity was 44.1 ± 12.5 mm Hg, and urine output during perfusion was 0.77 ± 0.44 mL · min^-1 · kg^-1. Preoperative values of creatinine, blood urea nitrogen, and total bilirubin were 1.1 ± 0.3, 17.6 ± 3.4, and 0.5 ± 0.2 mg/dL, respectively. These peak values within 1 week after the operation were 1.6 ± 0.7, 36.5 ± 14.2, and 2.1 ± 1.1 mg/dL, respectively. Although one patient (patient 4) with preoperative renal dysfunction (values of creatinine and creatinine clearance were 1.8 mg/dL and 39.4 mL/min, respectively) had renal failure and hemodialysis was initiated on the 84th postoperative day, he was weaned from the dialysis. The others had no postoperative complications, and all 8 patients survived the operation.

Discussion

It is especially important to protect the dysfunctional abdominal organs during distal anastomosis in aortic arch repair. Profound hypothermia with circulatory arrest has been presented by Griepp and colleagues, ² and Cooley and coworkers ³ have also used open distal anastomosis with hypothermia. In these techniques, however, the theoretical risk of air embolism is increased, suction of the blood is required, and some ischemic damage to the lower half of the body occurs if distal anastomosis is prolonged. An occlusion catheter technique allowing perfusion of the abdominal organs as in conventional cardiopulmonary bypass has been reported by Hirose and associates ⁴ to solve these problems. Ng and Ochsner ⁵ have designed an aortic balloon occlusion catheter to occlude the aorta and to control bleeding in patients with ruptured aortic aneurysms. In the occlusion catheter technique it was inserted retrogradely and blindly into the descending thoracic aorta through the femoral artery for distal aortic occlusion during aortic arch repair. It is difficult or impossible and may cause aortic dissection or perforation to insert the catheter if the abdominal aorta or the iliac artery is meandering, stenotic, or aneurysmal. The authors therefore have developed an original aortic balloon occlusion catheter (MD-21010; Sumitomo Bakelite, Tokyo, Japan), a 10F catheter that is reinforced with a wire to avoid being pushed back by retrograde perfusion through the femoral artery. ⁶ The catheter can be antegradely inserted into the descending thoracic aorta through the opened aortic arch by adequate handling. Inserting it is easy and sure and causes little disturbance to the distal anastomosis. Moreover, a new original 21F aortic balloon occlusion catheter with a 14F perfusion lumen (MD-21020, Sumitomo Bakelite) has been recently developed (Figure 1). ¹ It is possible to perfuse antegradely the lower half of the body during distal anastomosis by using the catheter, even though retrograde perfusion through the femoral artery is impossible or inadequate in patients with stenosis, occlusion, or aneurysm of the abdominal aorta or the iliac artery. Another advantage is to avoid embolism caused by retrograde perfusion through the femoral artery if a concomitant abdominal aortic aneurysm has mural thrombi. Antegrade perfusion for the lower half of the body by using the aortic balloon occlusion catheter with a perfusion lumen in patients with concomitant abdominal aortic aneurysm or atheroscrelosis obliterans is recommended as a useful supportive technique to protect against ischemia or embolism of the abdominal organs.

References

1. Takagi H, Hirose H, Matsumoto K, Fuwa S, Murakawa S, Mori Y, et al. A trial of antegrade perfusion to the lower half of the body with selective cerebral perfusion for repair of aortic arch aneurysm combined with atherosclerosis obliterans. Jpn J Thorac Surg. 1995;48:873-6.
   
2. Griepp RB, Stinson EB, Hollingsworth JF, Buehler D. Prosthetic replacement of the aortic arch. J Thorac Cardiovasc Surg. 1975;70:1051-63.[Abstract]
   
3. Cooley DA, Ott DA, Frazier OH, Walker WE. Surgical treatment of aneurysms of the transverse aortic arch: experience with 25 patients using hypothermic techniques. Ann Thorac Surg. 1981;32:260-72.[Abstract]
   
4. Hirose H, Kawashima Y, Shirakura R, Matsuda H, Nakano S, Adachi S. Use of the balloon catheter for distal occlusion of the aorta in prosthetic replacement of aortic arch aneurysms. Ann Thorac Surg. 1985;39:538-40.[Abstract]
   
5. Ng AC, Ochsner EC. Use of Fogarty catheter tamponade for ruptured abdominal aortic aneurysms. Am J Roentgenol. 1977;128:31-3.[Abstract]
   
6. Sasaki H, Umeda S, Kokubo M, Koike S, Murakawa S, Mori Y, et al. A case of ruptured pseudoaneurysm of the aortic arch associated with hemoptysis and hoarseness. Jpn J Thorac Surg. 1990;43:133-7.
   

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