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J Thorac Cardiovasc Surg 2003;125:952-953
© 2003 The American Association for Thoracic Surgery
Brief Communications |
From the Division of Thoracic and Cardiovascular Surgery, Hannover Medical School, Hannover, Germany.
Received for publication Dec 18, 2001. Accepted for publication Aug 16, 2002. Address for reprints: Matthias Karck, MD, Division of Thoracic and Cardiovascular Surgery, Hannover Medical School, D-30623 Hannover, Germany.
Stanford type A acute aortic dissection (AADA) is still a surgical challenge. Femoral cannulation remains the standard option for surgical repairs of AADA. However, retrograde perfusion has a potential risk of embolization of atheromatous debris, extension of dissection, and malperfusion. We hereby present our experiences with direct cannulation of the dissected ascending aorta in patients with AADA (Figure 1).
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Between January 1998 and September 2000, 41 patients had a surgical repair of AADA with median sternotomy in our hospital. Among this population, 14 patients had ascending aortic or proximal arch cannulation to initiate cardiopulmonary bypass (CPB). Nine patients had DeBakey type I and 5 had DeBakey type II aortic dissection. CPB was initiated with aortic cannulation at the dissected site in all but 4 of the patients with DeBakey type II aortic dissection. There were 4 female and 6 male patients aged 59 ± 11 years (range, 41-77 years). Two patients had sealed rupture of the ascending aorta, and one of them had a pericardial effusion.
After median sternotomy and longitudinal pericadiotomy, a less dissected or nondissected cannulation site is cautiously sought and determined by means of palpation and transesophageal echocardiography. By using normal double-purse-string sutures, the aortic cannula is fixed snugly. Then CPB is commenced with a 2-stage venous cannula. After the aorta is crossclamped and opened with a left ventricular vent, cardioplegic solution is infused directly into the coronary ostium, establishing cardioplegic arrest. The patient is cooled to 28°C, and systemic arterial flow is totally arrested. Antegrade cerebral perfusion with oxygenated cold blood is started by using cerebral oxygenation monitoring. During this circulatory arrest, the aortic cannula is removed, and the aorta is inspected. If the tear is found in the aortic arch, then replacement of the arch is performed with or without an elephant trunk. If the tear is confined to the ascending aorta, a graft is sutured to the distal ascending aorta. Gelatin-resorcin-formaldehyde glue is used for reinforcement of the anastomosis site. Antegrade cerebral perfusion is ceased, and CPB is resumed with the perfusion cannula directly reinserted into the graft. A crossclamp is applied to the graft, and the patient is rewarmed. During the rewarming phase, the appropriate procedures for a proximal aorta and aortic valve are performed.
The operations performed were ascending aortic replacement in 1 patient, ascending aortic replacement plus hemiarch replacement in 3 patients, ascending aortic replacement plus total arch replacement in 1 patient, Bentall procedure plus hemiarch replacement in 1 patient, David procedure plus hemiarch replacement in 3 patient, and aortic valve replacement plus ascending aortic replacement in 1 patient. The average duration of CPB was 153 ± 40 minutes. The average duration of aortic crossclamping was 112 ± 38 minutes.
There were no complications related to the arterial cannulation to establish CPB. No intraoperative malperfusion was found during CPB. There were no in-hospital deaths. Postoperative complications were respiratory failure in 1 patient, bleeding in 1 patient, pancreatitis in 1 patient, and Brown-Séquard syndrome in 1 patient.
Discussion
Femoral cannulation has been the standard technique for surgical repair of AADA. However, when retrograde femoral perfusion is commenced, blood flow might be directed through a distal re-entry site into the false channel. Absence of an entry in the ascending aorta or exclusion of such a tear by application of the aortic crossclamp might lead to exclusive perfusion of the false channel, which then expands at the cost of branch vessels arising from the true lumen.
1,2 Furthermore, the retrograde perfusion has a potential risk of embolization of the atheromatous debris. Westaby and colleagues 3 pointed out that antegrade perfusion provides a lower risk of cerebral embolism than retrograde perfusion in their distal arch and descending aortic operations.
The first successful report of this technique was published in 1998. 4 We started to use this simple technique in 1998, and the frequency of use of this technique is growing up to 42.9% of cases in 2000. We try to cannulate at a nondissected or less dissected segment, as determined by means of palpation, to perfuse the true lumen. This is usually the left lateral portion of ascending aorta adjacent to the pulmonary artery. Transesophageal echocardiography showing the image of the ascending aorta provides important information that can guide the proper positioning of the perfusion cannula. The wall of the dissected aorta looks fragile but is capable of supporting the aortic cannula with double purse-string sutures. We will not abolish use of the femoral artery and axillary artery, but one should be aware that this simple method could be applied safely in many cases of AADA.
References
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