Interact CardioVasc Thorac Surg 2009;8:577-578. doi:10.1510/icvts.2008.201665
© 2009 European Association of Cardio-Thoracic Surgery
Brief communication - Aortic and aneurysmal |
An inexpensive technique of selective antegrade cerebral perfusion
Dhananjay Malankar,
Sachin Talwar,
Neeti Makhija and
Shiv Kumar Choudhary*
Cardiothoracic Sciences Center, All India Institute of Medical Sciences, New Delhi, India
Received 29 December 2008;
received in revised form 2 February 2009;
accepted 10 February 2009
*Corresponding author. Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi-110029, India. Tel.: +91-11-26588500; fax: +91-11-26588663.
E-mail address: shivchoudhary{at}hotmail.com (S.K. Choudhary).
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Abstract
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Surgery on the aortic arch is often combined with intraluminal cannulation of the arch vessels for selective antegrade cerebral perfusion and better neurological protection. We report a simple and inexpensive technique for this purpose.
Key Words: Aortic aneurysm; Cerebral perfusion; Neurological protection
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1. Introduction
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Deep hypothermic circulatory arrest (DHCA) in combination with selective antegrade cerebral perfusion (SACP), is a well-established method of brain protection in aortic arch surgery [1]. Right subclavian/axillary artery (RSCA) cannulation or direct arch vessel cannulation are used frequently for this purpose. Direct intraluminal cannulation of arch vessel is preferred when cardiopulmonary bypass is established with femoral arterial cannulation and is also desirable in the setting of acute dissection to avoid clamping the arch vessel for fear of damaging it. Currently, intraluminal direct cannulation is carried out using commercially available balloon tip antegrade cerebral perfusion cannulae and a separate pump is used for SACP. The commercially available SACP cannulae are expensive and often not available in several countries. We report our experience with an inexpensive and equally effective cannulation technique and perfusion circuit for SACP.
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2. Technique
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For monitoring of the arterial pressure, an arterial line is placed in the right radial artery. The 3/8 inch tubing of the arterial line was bifurcated by using a 3/8 inch ‘Y’ connector and 3/8 inch extra tubing (Fig. 1). The line A is used either for ascending aortic or femoral arterial cannulation. Line B is bifurcated again in a similar fashion. Two cuffed endotracheal tubes, one No. 6 (internal diameter=6 mm, and external diameter=8.2 mm) and another No. 5.5 (internal diameter=5.5 mm, and external diameter=7.6 mm) are connected to both the divisions of line B using two 3/8–1/4 inch straight perfusion connectors (Fig. 2).
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Fig. 1. The 38 inch tubing of the arterial line is bifurcated by using a 38 inch ‘Y’ connector and 38 inch extra tubing. The line A is used either for ascending aortic or femoral arterial cannulation. Line B is bifurcated again in a similar fashion.
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Fig. 2. Line B is bifurcated again in a similar fashion. Two cuffed endotracheal tubes, one No. 6 and another No. 5.5 are connected to both the divisions of line B using two 38–14 inch straight perfusion connectors.
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Local carbon-dioxide insufflation is continued at 10 l/min to minimize the risk of air embolism. The arch vessels are looped but are not snared or clamped. Once circulatory arrest is achieved and the aortic arch is opened, line A is clamped and line B is kept open. The arterial pump is started at a rate of approximately 100 ml/min. A No. 6 endotracheal tube is inserted in the innominate artery and a No. 5.5 endotracheal tube in the left common carotid artery (LCCA), and their balloons are inflated. Arterial flow is increased to 10 ml/kg of body weight, and increased further, if required, to maintain the right radial arterial pressure of around 50 mmHg. The left subclavian artery is cross-clamped during the procedure. As explained below, we do not measure the pressure in the left carotid artery routinely.
When the arch reconstruction is nearing completion, pump flow is reduced, line A is opened and line B is clamped. The balloons are deflated and the endotracheal tubes are removed with the patient in Trendeleberg position. Once the anastomosis is complete, aortic cross-clamp is reapplied on the graft just proximal to the origin of arch vessels and full cardiopulmonary bypass is re-established. The remainder of the procedure is carried out in the usual manner.
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3. Discussion
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Various methods of selective antegrade cerebral perfusion have been used in the past. Initially only right-sided unilateral SACP was practiced through right subclavian/axillary artery cannulation, after clamping the left common carotid artery and the left subclavian artery. Bilateral SACP became a routine practice after finding that stroke was more common after a strategy of unilateral rather than bilateral SACP [2].
Bilateral SACP is carried out in two ways. In the first method, the combination of right subclavian artery cannulation through a graft or a special arterial cannula, and a separate LCCA cannulation is required. In the second method, two separate cannulae are inserted in the innominate artery and the LCCA. The purpose of this report is not to discuss the advantages or disadvantages of various SACP strategies but only to report our easy and inexpensive method of intraluminal arch vessel cannulation.
Special custom-made balloon-tip cannulae for SACP are also available [3], but these are expensive and are not available universally. Previously, we have used retrograde coronary sinus perfusion cannulae for this purpose, but these cannulae are smaller, require snaring of arch vessels over the cannula and may damage the diseased arch vessels.
We do not measure left carotid artery pressure and hence there is no way to assess the distribution of blood. As the endotracheal tube in left common carotid artery is only one size smaller, ensuring adequate perfusion pressure in innominate system will ensure satisfactory perfusion pressure in left-sided cerebral circulation. Up until now, we have not faced any neurological hypo-perfusion related problem with this technique. The other alternative is to use a balloon-tip catheter with a pressure sensor at the tip, but again, it will be expensive.
We believe that the technique reported by us in this report is simple, reproducible and inexpensive.
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References
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- Olsson C, Thelin S. Regional cerebral saturation monitoring with near-infrared spectroscopy during SACP: diagnostic performance and relationship to postoperative stroke. J Thorac Cardiovasc Surg 2006;131:371–379.[Abstract/Free Full Text]
- Olsson C, Thelin S. Antegrade cerebral perfusion with a simplified technique: unilateral versus bilateral perfusion. Ann Thorac Surg 2006;81:868–874.[Abstract/Free Full Text]
- Kazui T. Simple and safe cannulation technique for selective antegrade cerebral perfusion. Ann Thorac Cardiovasc Surg 2001;7:186–188.[Medline]
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Abstract
1. Introduction