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J Thorac Cardiovasc Surg 2008;135:229
© 2008 The American Association for Thoracic Surgery

Letter to the Editor

Ascending aortic cannulation in acute type A aortic dissection: Is intraoperative brachiocephalic malperfusion a possibility?

Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pa

To the Editor:

I read with great interest the recent article by Dr Jakob and colleagues¹ detailing their pilot experience with direct cannulation of the ascending aorta in acute type A dissection (n = 8: 5 with preoperative cerebral malperfusion). Their method entailed primary venous exsanguination, cannulation of ascending aortic true lumen under direct vision, controlled deairing, followed by standard cardiopulmonary bypass after proximal aortic clamping.

The clinical consideration here is whether this cannulation technique protects against brachiocephalic malperfusion, given that 5 of 8 patients presented with brachiocephalic dissection and cerebral malperfusion in the setting of true lumen pulsatile perfusion.

The following questions relate to this consideration:

1 What intraoperative monitoring was used to detect brachiocephalic malperfusion?

2 Were any episodes of brachiocephalic malperfusion detected intraoperatively? If so, how were they managed?

3 Was surgical intimal fenestration above the ascending aortic clamp ever required to restore adequate brachiocephalic perfusion? In our practice, this management technique has been used successfully to correct innominate malperfusion detected intraoperatively by transcutaneous scanning of the right carotid artery.²

4 Was epiaortic ultrasound guidance for cannulation of the dissected ascending aorta ever considered? This imaging technique has been used successfully in this scenario.³ It can also confirm correct placement of the arterial cannula.

I congratulate the authors again on a fine study. I look forward to their feedback about these intraoperative considerations.

Footnotes

Financial support provided by the Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania

References

1. Jakob H, Tsagakis K, Szabo A, Wiese I, Thielmann M, Herold U. Rapid and safe direct cannulation of the true lumen of the ascending aorta in acute type A aortic dissection. J Thorac Cardiovasc Surg 2007;134:244-245.[Free Full Text]
   
2. Augoustides JGT, Kohl BA, Harris H, Pochettino A. Color-flow Doppler recognition of intraoperative brachiocephalic malperfusion during operative repair of acute type A aortic dissection: utility of transcutaneous carotid artery ultrasound scanning. J Cardiohorac Vasc Anesth 2007;21:81-84.
   
3. Inoue Y, Ueda T, Taguchi S, Kashima I, Koizumi K, Takahashi R, et al. Ascending aorta cannulation in acute type A aortic dissection. Eur J Cardiothorac Surg 2007;31:976-979.[Abstract/Free Full Text]
   

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): John G.T. Augoustides Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Augoustides, J. G.T. Search for Related Content PubMed Articles by Augoustides, J. G.T. Related Collections Related Article