Interact CardioVasc Thorac Surg 2007;6:652-653. doi:10.1510/icvts.2007.158097
© 2007 European Association of Cardio-Thoracic Surgery
Proposal for bail-out procedures - Cardiac general |
Bilateral axillary artery inflow in the treatment of a rare case of pseudocoartaction of the aortic arch
Alessandro Mazzola*,
Renato Gregorini,
Guglielmo DeCurtis and
Marco Ciocca
Cardiac Surgery Department, Ospedale Giuseppe Mazzini, Piazzale San Padre Pio, 64100 Teramo, Italy
Received 20 April 2007;
received in revised form 30 May 2007;
accepted 31 May 2007
*Corresponding author. Tel.: +39 0861 429690; fax: +39 0861 429687.
E-mail address: sandromaz{at}tin.it (A. Mazzola).
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Abstract
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The axillary artery is the preferred site for arterial cannulation in operations for ascending aorta and aortic arch replacement in order to reduce perfusion-related morbidity in acute dissection and to prevent cerebral embolism in atherosclerotic aneurysm. We present the case of a patient with a chronic dissection presenting as pseudocoartaction of the aortic arch in which bilateral axillary artery inflow was necessary to perfuse both ascending and descending aorta.
Key Words: Axillary artery; Aortic aneurysm; Cardiopulmonary bypass
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1. Introduction
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To avoid perfusion-related morbidity in aortic dissection and cerebral embolism in atherosclerotic aneurysm, the axillary arteries are used with increasing frequency for arterial inflow in the surgery of the ascending aorta and aortic arch [1–5]. In the setting of aortic dissection multiple site of arterial cannulation may be necessary to prevent malperfusion; we describe bilateral axillary inflow in a case of chronic dissection of ascending aorta previously operated on for distal arch and descending thoracic aorta replacement.
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2. Case report
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A 52-year-old man was admitted to our department because of a sudden increase of the right arm pressure and normal left arm pressure. Two years earlier he had the descending thoracic aorta and the distal aortic arch replaced, after the origin of the left carotid artery for chronic B aortic dissection. The attempt to reduce blood pressure caused a sharp increase in serum creatinine. Renal scintigraphy ruled out a kidney malperfusion. Transthoracic echocardiography revealed a moderately calcified bicuspid aortic valve but no intimal flap was evident into the ascending aorta. Magnetic resonance of the aorta distally to repair showed no variation of the false lumen compared to the previous postoperative controls and a good perfusion of both kidneys, one from the false and the other from the true lumen. Proximally to the prosthesis, the magnetic resonance revealed aortic dissection with a flap originating just above the coronary ostia and terminating at the site of the anastomosis of the arch with the prosthesis. The true lumen was flattened by the false lumen creating the unusual presentation of pseudocoartaction of the arch (Fig. 1). To avoid any risk of malperfusion during extracorporeal circulation, we planned the use of both axillary arteries for arterial inflow by the interposition of an 8-mm vascular prosthesis (Fig. 2). Right and left radial artery pressure monitoring gave a reliable indication of symmetrical perfusion pressure during cooling and rewarming. When rectal temperature reached 25 °C the innominate artery was clamped and antegrade selective cerebral perfusion was started as previously described [1]. The proximal aortic arch was replaced with separate reimplantation of the carotid artery and the innominate artery on a branched arch prosthesis. The prosthesis was clamped proximally and the entire circulation of the body was resumed through both axillary arteries. During rewarming a modified (buttons) Bentall operation was carried out to complete the surgical procedure. The postoperative course was uneventful and the patient was discharged from the hospital six days later.
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Fig. 1. Magnetic resonance imaging of the thoracic aorta. (a) The true lumen is completely flattened in the ascending aorta. (b) The aortic arch is obstructed by the intimal flap (white arrow).
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Fig. 2. The schematic drawing shows the intimal flap realising the pseudocoartaction of the arch. Both axillary arteries are connected to an 8-mm. vascular prosthesis for arterial inflow (black arrows).
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3. Discussion
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The right and the left axillary artery were proposed as arterial inflow in severely atheromatous aorta and in type A aortic dissection [2–4], which to date is considered the preferred arterial site cannulation for ascending and aortic arch replacement [5]. In atherosclerotic aneurysms the advantage of axillary artery cannulation is the prevention of cerebral embolism, while in the setting of aortic dissection the avoidance of malperfusion is the major goal [2–5]. Bilateral axillary arterial perfusion has been proposed by Kurisu et al. [6] in the surgery of thoracic aorta to minimize cerebral embolic complications. In our case the clinical presentation clearly disclosed the malperfusion of the true lumen in the ascending aorta, and the awareness of the presence of the false lumen in the descending thoracic and abdominal aorta suggested that we used both the axillary arteries to make sure to perfuse the brain by the right axillary artery and the viscera through the prosthesis by the left axillary artery. We believe that bilateral axillary artery inflow is a safe and effective means to prevent malperfusion in the setting of aortic dissection and should be utilized more frequently. The proposed technique is reproducible and easy to do without any significant extended surgical time. The only limitation could be the severe atherosclerotic or dissecting process involving the axillary artery.
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References
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- Sabik JF, Lytle BW, McCarthy PM, Cosgrove DM. Axillary artery: an alternative site of arterial cannulation for patient with extensive aortic and peripheral vascular disease. J Thorac Cardivasc Surg 1995; 109:885–891.[Abstract]
- Baribeau YR, Westbrook BM, Charlesworth DC, Maloney CT. Arterial inflow via an axillary artery graft for the severely atheromatous aorta. Ann Thorac Surg 1998; 66:33–37.[Abstract/Free Full Text]
- Neri E, Massetti M, Capannini G, Carone E, Tucci E, Diciolla F, Prifti E, Sassi C. Axillary artery cannulation in type A aortic dissection operations. J Thorac Cardiovasc Surg 1999; 118:324–329.[Abstract/Free Full Text]
- Strauch JT, Spielvogel D, Lauten A, Lansman SL, McMurtry K, Bodian CA, Griepp RB. Axillary artery cannulation: routine use in ascending and aortic arch replacement. Ann Thorac Surg 2004; 78:103–108.[Abstract/Free Full Text]
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Abstract
1. Introduction