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Rapid and safe establishment of cardiopulmonary bypass in repair of acute aortic dissection: improved results with double cannulation

Department of Cardiovascular Surgery, National Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka, 565-8565, Japan

Received 13 November 2007; received in revised form 26 June 2008; accepted 1 July 2008

Presented at the 21st Annual Meeting of the European Association for Cardio-thoracic Surgery, Geneva, Switzerland, September 16–19, 2007.

Corresponding author. Tel.: +81-6-6833-5012; fax: +81-6-6872-7486.

E-mail address: minatoya{at}hsp.nsvc.go.jp (K. Minatoya).

	Abstract

Top Abstract 1. Introduction 2. Patients and methods 3. Operative techniques 4. Results 5. Discussion Appendix A References

 
There is no agreement at present as to which is the optimal site for artery cannulation for cardiopulmonary bypass in repair of acute aortic dissection (AAD). We have employed right axillary artery cannulation (RAAC) in combination with femoral artery cannulation to overcome the drawbacks of single cannulation. From January 2000 to August 2006, 88 patients underwent emergency surgical repair of the aortic arch (mean age 65±13 years, 37 men) for AAD. All operations were performed under hypothermic circulatory arrest with antegrade selective cerebral perfusion. Preoperatively, nine patients were in shock and 18 patients showed malperfusion. The average duration of circulatory arrest was 52±17 min and that of myocardial ischemia was 135±53 min. Total aortic arch replacement was done in 47 patients and hemiarch aortic replacement in 41. The hospital mortality rate was 2.3% (2 of 88); the fatal cases were among those who were in shock preoperatively. The perioperative stroke rate was 5.7% (5 of 88). The hospital mortality rate of the 25 patients with preoperative malperfusion was 4.0% (1 of 25); the fatal case had coronary malperfusion. Our approach for AAD was associated with a low mortality even in patients with malperfusion.

Key Words: Acute aortic dissection; Cannulation; Axillary artery

	1. Introduction

Top Abstract 1. Introduction 2. Patients and methods 3. Operative techniques 4. Results 5. Discussion Appendix A References

 
Management of DeBakey type I acute aortic dissection is still a surgical challenge. At present, there is no agreement as to which is the optimal site for artery cannulation for cardiopulmonary bypass in repair of acute aortic dissection (AAD). We have employed the right axillary artery cannulation (RAAC) in combination with femoral artery cannulation to overcome the drawbacks of single cannulation.

	2. Patients and methods

Top Abstract 1. Introduction 2. Patients and methods 3. Operative techniques 4. Results 5. Discussion Appendix A References

 
From January 2000 to August 2006, 88 patients underwent emergency surgical repair of the aortic arch (mean age 65±13 years, 37 men) for AAD. All patients underwent RAAC and femoral artery cannulation, and the operations were performed under hypothermic circulatory arrest with antegrade selective cerebral perfusion. Preoperatively, nine patients were under deep shock and two required cardiopulmonary resuscitation; moreover, 25 patients showed malperfusion. Of these 25 patients, four had coronary malperfusion, 11 had cerebral malperfusion, four had visceral malperfusion, six had upper extremity malperfusion, and three patients had lower extremity malperfusion. All patients were operated on within two weeks from the onset of AAD.

All patients were operated on an emergent basis after the onset of aortic dissection within two weeks. Our surgical principle for acute aortic dissection is exclusion of intimal tear. If aortic arch is severely dissected or has a massive false lumen, even without an intimal tear in transverse arch extended total arch replacement was performed.

	3. Operative techniques

Top Abstract 1. Introduction 2. Patients and methods 3. Operative techniques 4. Results 5. Discussion Appendix A References

 
For the graft replacement, a collagen-woven or gelatin-impregnated knitted Dacron graft was used. One branched graft was used for hemiarch replacement and a quadrifurcated graft was employed for total arch replacement. The elephant trunk technique was additionally used for total arch replacement. Open distal anastomosis was performed, and the femoral and right axillary arteries were used as cannulation sites for arterial return. The right axillary artery was exposed through a 5–7 cm skin incision at the right axilla. Cardiopulmonary bypass was started with RAAC, and then the femoral perfusion was commenced. Reperfusion and rewarming were always achieved in an antegrade manner through the side branch of the graft.

For reinforcement of the stump of the aorta, Gelatin-Resorcin-Formaldehyde (GRF) glue or Bioglue was applied to obliterate the false lumen in most patients. Besides the use of a chemical glue, all stumps were reinforced with Teflon felt strips.

Antegrade selective cerebral perfusion was maintained with the RAAC and a balloon-tip cannula inserted directly in the left common carotid artery and the left subclavian artery from inside the aortic arch. Cerebral perfusion flow was maintained at 300–500 ml/min, the mean pressure in the superficial temporal arteries ranged from 40–60 mmHg, and the nasopharyngeal temperature ranged from 20–28 °C.

Concomitant procedures included aortic valve resuspension in 54 patients, aortic root replacement in three, aortic root reconstruction in four, and CABG in two patients.

	4. Results

Top Abstract 1. Introduction 2. Patients and methods 3. Operative techniques 4. Results 5. Discussion Appendix A References

 
The average duration of the operation was 461±161 min, that of cardiopulmonary bypass was 246±168 min. The average duration of circulatory arrest was 52±17 min and that of myocardial ischemia was 135±53 min. Total aortic arch replacement was done in 47 patients and hemiarch replacement in 41. The hospital mortality rate was 2.3% (2 of 88); the two fatal cases were among the patients who had been in shock preoperatively. The perioperative stroke rate was 5.7% (5 of 88).

The hospital mortality rate of 25 patients with preoperative malperfusion was 4.0% (1 of 25); the fatal case was a patient that who had presented coronary malperfusion, which led to myocardial infarction. Three (27.3%) of the 11 patients with preoperative cerebral malperfusion suffered a stroke. Myonephropathic metabolic syndrome occurred in 1 (33.3%) of the three patients with preoperative malperfusion of the lower extremities.

	5. Discussion

Top Abstract 1. Introduction 2. Patients and methods 3. Operative techniques 4. Results 5. Discussion Appendix A References

 
Several techniques to establish a cardiopulmonary bypass for the emergency treatment of AAD have been reported [1–3]. Among them, axillary artery cannulation is currently becoming a new standard technique [4, 5]. The axillary artery was generally cannulated at some point within its proximal segment according to previous reports. Exposure of the proximal segment of the axillary artery usually requires 10–15 min, and it takes longer when a short graft is interposed. In our patients, we cannulated the artery at a point next to the brachial artery, and required only a few minutes to expose it because the artery locates more superficially at this level. Accessibility is a great benefit for the rapid establishment of cardiopulmonary bypass in an emergency situation. Another benefit of this approach is the non-interference with the midsternal incision. The retractor for the mid-sternal incision sometimes interferes with the surgical field for the exposure of the proximal segment of the axillary artery. This interference is a significant drawback in an emergency situation such as surgical repair of AAD.

The drawback of RAAC is the low flow rate. The diameter of the distal segment of the axillary artery is smaller than that of the proximal segment, and we had to use 10–14 Fr thin-wall cannulas. The maximum flow rate was only 1.0–1.5 l/min with the 10 Fr cannula, therefore another aortic return was necessary and we opted for the femoral artery for this purpose. Femoral cannulation is one of the good options for arterial return in patients with AAD [6], and we believe it is safer when used combined with RAAC [7]. The flow through RAAC perfuses the aortic arch and interferes with the retrograde flow from the femoral artery cannula, avoiding the risk of retrograde perfusion to the brain. Exposure of the femoral artery is as easy and as quick as that of the distal axillary artery. Cardiopulmonary bypass is established rapidly even when double cannulation is required.

The malperfusion observed in AAD is multifactorial, but it is mainly due to complex anatomic interactions between the true lumen and the false lumen along the entire dissected aorta. To overcome life-threatening malperfusion, arterial cannulation should be placed into the true lumen within a short time. We think a rapid cannulation of the true lumen via the axillary artery lessens the risk of cerebral ischemia. When malperfusion due to AAD persists after establishment of cardiopulmonary bypass, placing another cannula is one of the solutions. If monitoring of peripheral arterial pressure and flow shows abnormal signs, left axillary artery or ipsilateral femoral artery cannulation should be considered. Thus, multiple cannulation may minimize complications due to malperfusion during cardiopulmonary bypass.

In conclusion, RAAC combined with femoral arterial cannulation during repair of AAD was safe and secure to establish cardiopulmonary bypass within a short time. This approach for AAD was associated with a low mortality rate even in patients with malperfusion.

	Appendix A

Top Abstract 1. Introduction 2. Patients and methods 3. Operative techniques 4. Results 5. Discussion Appendix A References

 
Conference discussion

Dr. M. Turina (Zurich, Switzerland): Nowadays, we usually start moving from the definition of hospital mortality to 30-day mortality and 3-month mortality. This will be in the new guidelines about the reporting of mortality. How is your 1-month and 3-month mortality?

Dr. Minatoya: Actually, this is 30 days mortality.

Dr. Turina: The fact is that many patients get removed from hospital to another facility.

Dr. Minatoya: Right. But in our system, the patients do not move out until well, the patient passed away. Few patients who had a big stroke moved out to a sort of caring house. They are usually staying in our hospital for a long time.

Dr. P. Urbanski (Bad Neustadt, Germany): The double cannulation is really very good idea. We use it occasionally but with one difference.

In patients with cerebral malperfusion, you have often patients with narrowed arterial lumen in both carotid arteries. And the second line in the axillary artery is localized also central to the carotid arteries. To ensure a sufficient cerebral perfusion during cardiopulmonary bypass, we place a second line in the carotid artery directly under bifurcation because the best method of cerebral protection during circulatory arrest is useless if the cerebral perfusion is not sufficient during cardiopulmonary bypass.

Dr. Minatoya: I completely agree with you. The axillary artery is rarely dissected, so we can put the cannula inside the true lumen basically. After establishment of the circulatory arrest, we can see the orifice of arch vessels and usually we can find a good backflow, then we do not worry about it so much. But, of course, we put the two cannulas inside the rest of the arch vessels.

Dr. S. Kucuker (Ankara, Turkey): There are many groups which report that single cannulation is satisfactory, especially for cooling. For the rewarming period, extra flow may be necessary. In that case, you can directly cannulate the graft for antegrade flow, and you will avoid to use retrograde flow at any time.

Dr. Minatoya: We usually use one branched graft for hemiarch replacement, and four branched graft for total arch replacement. In short, we have one branch for aortic return to rewarm the patient besides the axillary arterial cannulation.

	References

Top Abstract 1. Introduction 2. Patients and methods 3. Operative techniques 4. Results 5. Discussion Appendix A References

 

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4. Pasic M, Schubel J, Bauer M, Yankah C, Kuppe H, Weng YG, Hetzer R. Cannulation of the right axillary artery for surgery of acute type A aortic dissection. Eur J Cardiothorac Surg 2003;24:231–235; discussion 235–236.[Abstract/Free Full Text]
5. Moizumi Y, Motoyoshi N, Sakuma K, Yoshida S. Axillary artery cannulation improves operative results for acute type a aortic dissection. Ann Thorac Surg 2005;80:77–83.[Abstract/Free Full Text]
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7. Numata S, Ogino H, Sasaki H, Hanafusa Y, Hirata M, Ando M, Kitamura S. Total arch replacement using antegrade selective cerebral perfusion with right axillary artery perfusion. Eur J Cardiothorac Surg 2003;23:771–775; discussion 775.[Abstract/Free Full Text]

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