Interact CardioVasc Thorac Surg 2008;7:133-135. doi:10.1510/icvts.2007.160564
© 2008 European Association of Cardio-Thoracic Surgery
Proposal for bail-out procedures - Cardiac general |
Innovative technique to treat acute cerebral and peripheral malperfusion during type A aortic dissection repair
Pasquale Totaroa,* and
Vincenzo Arganob
a Cardiac Surgery, Civic Hospital, 25123 Brescia, Italy
b Cardiac Surgery, Villa Maria Eleonora Hospital, Palermo, Italy
Received 31 May 2007;
received in revised form 3 October 2007;
accepted 4 October 2007
*Corresponding author. Via San Vincenzo 38, 20123 Milano, Italy. Tel.: +39 349 8465085; fax: +39 030 3995004.
E-mail address: ptotaro{at}yahoo.com (P. Totaro).
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Abstract
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Cerebral and/or visceral malperfusion during CPB is a potentially dramatic situation which can be easily misunderstood if a complete monitoring of arterial pressure and cerebral saturation is not available. Here we present a case in which we could promptly diagnose cerebral and visceral malperfusion just after starting cardiopulmonary bypass. Use of an original and unusual method for distal perfusion allowed us to treat malperfusion, uneventful cooling of the patient down to deep hypothermia and to complete the procedure in circulatory arrest as planned.
Key Words: Malperfusion; Aortic surgery; Acute aortic dissection
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1. Introduction
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Visceral and/or cerebral malperfusion is a potentially dramatic complication of cardiopulmonary bypass during acute type A aortic dissection repair.
Here we present a case in which cerebral and peripheral malperfusion was managed using an innovative technique to adequately perfuse the full body until deep hypothermia was achieved.
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2. Case description
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A 45-year-old patient was referred to our department with the diagnosis of acute type A aortic dissection. At admission he was in a relatively stable condition (arterial pressure left arm 110/70, sinus rhythm 76 beats/min) with infusion of TNG/SNP, and was still complaining of chest and back pain. At examination right radial pulse was very soft and right femoral pulse was absent. Diagnosis was confirmed at CT scan and TE echo and the patient was therefore taken into OR. Despite the right radial pulse being absent we attempted to cannulate the right axillary artery, which is rarely involved completely by the dissection. In this case, however, the axillary artery was completely dissected and the presence of an extended false lumen, with just a virtual true lumen, made the cannulation impossible. Based on the presence of a good femoral arterial wave, we, therefore, exposed and cannulated the left common femoral artery, which did not show clear signs of dissection. After arterial cannulation, the sternum was opened and the heart was exposed. The ascending aorta was completely dissected towards the arch, which was also dissected. The right atrium was cannulated with a standard two-stage cannula and cardiopulmonary bypass (CPB) was started, using a centrifugal pump, for cooling down to 18 °C. After 5 min of full-flow (2.5 l/min/m2) CPB, arterial wave from left side disappeared and near infrared spectroscopy (INVOS, Somanetics, Troy, MI) showed important cerebral oxygen desaturation in both hemispheres (value <40% from baseline). We realized that the retrograde flow was causing cerebral malperfusion, probably due to a distal re-entry tear on the descending aorta. Due to the impossibility of an alternative site and the instability of the clinical condition, we decided to attempt a complete antegrade perfusion using a double Y-shaped connector on the arterial line. CPB was then stopped, the aorta was opened and antegrade flow was restarted as shown in Fig. 1. Briefly, a size 8.5 endotracheal tube (Hi-Contour) connected to a standard 24 Fr arterial cannula was inserted into the descending aorta and, once the tube cuff (30 mm) was inflated, antegrade flow was started allowing for visceral organs perfusion. In the meantime, antegrade cerebral perfusion was obtained, as a routine technique for aortic arch surgery, by means of selected cannulation of epiaortic vessels using balloon-tip DLP cannulae (14 F for brachiocephalic trunk and 12 F for left carotid artery and left subclavian artery). Once all cannulae were placed, full flow CPB was restarted achieving a mean perfusion pressure between 50–70 mmHg with no sign of leakage at the distal end of the endotracheal tube. Satisfactory cerebral saturation was restored and good urine output confirmed a good general perfusion. The patient was cooled down to 18 °C and the operation was then completed in the usual fashion. Complete aortic arch reconstruction with elephant trunk and reimplantation of epiaortic vessels was performed using a 26 mm straight Dacron tube with an external 10 mm branch. Valve sparing aortic root reconstruction was then performed by means of a 28 m straight Dacron tube according to the David procedure. The patient recovered uneventfully from the operation and was discharged home after 15 days.
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Fig. 1. Picture showing the position of four cannulae to achieve a complete antegrade perfusion of epiaortic vessels and peripheral organs.
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3. Discussion
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Cerebral malperfusion during CPB is a potentially dramatic situation which can be easily misunderstood if double radial artery wave and cerebral saturation are not monitored. Such a complication is related to the extent of the intimal flap and seems to be increased by the retrograde flow into the thoracic aorta following femoral artery cannulation [1, 2] despite, on the other hand, some studies having confirmed the safety of femoral artery approach [3]. To minimize the risk of malperfusion, axillary artery cannulation which avoids retrograde flow in the dissected aorta, has been proposed as first choice site of arterial cannulation [2, 4]. Alternative sites of cannulation, such as carotid artery, have also been proposed for selected patients [5]. In this case we were not able to achieve satisfactory perfusion neither using axillary cannulation (our first choice) nor using femoral approach. Fortunately, the use of this innovative method allowed us to uneventfully cool the patient down to deep hypothermia and complete the procedure in circulatory arrest as planned, thus solving the problems of malperfusion. We were inspired to such a technique by a paper by Neri et al. [6] who reported the use of an endotracheal tube as a ‘modified’ cannula to obtain an endo-clamping effect and to achieve cerebral perfusion during descending thoracic aorta surgery. We modified his technique to obtain physiological antegrade perfusion and easy systemic cooling. A similar concept using a new cannula and mild hypothermia was also recently reported by Bakhtiary et al. [7]. In this patient we were able to achieve a full flow with adequate perfusion of full body, nevertheless, we still decided for deep hypothermia for a comfortable distal end anastomosis. Following this successful case, however, we have employed the same technique in three further elective patients undergoing arch replacement, allowing for continued antegrade distal perfusion at 25 °C. We conclude that the use of an endotracheal tube as an alternative cannula to obtain antegrade perfusion and aortic endoclamping is a safe and low-cost technique, which could be extremely helpful in selected situations.
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References
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- Ergin MA, Phillips RA, Galla JD, Lansman SL, Mendelson DS, Quintana CS, Griepp RB. Significance of distal false lumen after type A aortic dissection repair. Ann Thorac Surg 1994; 57:820–825.[Abstract]
- Neri E, Massetti M, Capannini G, Carone E, Tucci E, Di Ciolla 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]
- Fusco DS, Shaw RK, Tranquilli M, Kopf GS, Elefteriades JA. Femoral cannulation is safe for type A dissection repair. Ann Thorac Surg 2004; 78:1285–1289.[Abstract/Free Full Text]
- Strauch JT, Spielvogel D, Lauten A, Lansman SL, McMurtry K, Bodian CA, Griepp RB. Axillary artery cannulation: routine use in in ascending aorta and aortic arch replacement. Ann Thorac Surg 2004; 78:103–108.[Abstract/Free Full Text]
- Urbansky PP. Carotid artery cannulation in acute aortic dissection with malperfusion. J Thorac Cardiovasc Surg 2006; 131:1398–1399.[Free Full Text]
- Neri E, Capannini G, Carone E, Tucci E, Sassi C. Emergency cannulation for proximal perfusion in descending thoracic aorta procedures. Ann Thorac Surg 1999; 68:587–589.[Abstract/Free Full Text]
- Bakhtiary F, Dogan S, Risteski P, Ackermann H, Oezaslan F, Kleine P, Moritz A, Aybek T. Mild hypothermic (30 °C) body perfusion during replacement of the aortic arch with a novel arterial perfusion cannula. J Thorac Cardiovasc Surg 2007; 133:1637–1639.[Free Full Text]
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Abstract
1. Introduction