Ann Thorac Surg 1996;61:1259-1261
© 1996 The Society of Thoracic Surgeons
Case Report
Circulatory Arrest in a Reoperation for Brachiocephalic Arterial Occlusive Disease
Elias A. Bastounis, MD,
Leonidas K. Hadjinikolaou, MD,
David P. Taggart,
MD(Hons),
Constantine A. Gouvas, MD,
Attiya S. Khan, MD,
Demitrio G. Boulafendis, MD
Department of Cardiovascular Surgery, Spring Branch Medical Center, Houston, Texas
Accepted for publication September 27, 1995.
 |
Abstract
|
|---|
We report a patient with multiple brachiocephalic arterial occlusive disease who suffered failure of a bifurcated aorto-carotid artery graft. Profound hypothermic circulatory arrest provided adequate cerebral protection during redo aorto-brachiocephalic arterial grafting.
|
Introduction
|
|---|
Reoperation for recurrent multiple brachiocephalic arterial occlusions and stenoses has been considered a rare condition. It is generally recognized that such redo procedures are technically more difficult and are associated with a higher risk of embolism than operation for primary disease. Hypothermic circulatory arrest may offer significant surgical advantages in these cases, but there has been limited experience of its use in patients with severely compromised cerebral blood flow. This article reports the application of profound hypothermic circulatory arrest in a complex reoperation in a patient with recurrent multiple brachiocephalic arterial occlusive disease.
A 66-year-old woman was admitted due to frequent episodes of dizzy spells (8 to 12 per day) associated with numbness of left arm and face for the last 6 months. Eleven years before admission, a bifurcated bypass graft from the ascending aorta to both common carotid arteries had been placed, due to severe atherosclerotic disease of the innominate and both common carotid arteries. That procedure was carried out via a median sternotomy. She was a heavy smoker with a positive family history of atherosclerotic disease. Physical examination revealed bruits in both carotid arteries.
Aortography showed graft failure with occlusion of the right limb and 90% stenosis of the left limb. The innominate, the right subclavian, and both common carotid arteries were occluded. There was also a 75% stenosis in the origin of the left subclavian artery, 95% stenosis of the right coronary artery, and diffuse aortoiliac disease.
The operation was performed through a median sternotomy. The femoral artery was exposed in the right groin and cannulated with an 18F arterial perfusion cannula (Research Medical, Inc, Midvale, UT). After dissection of the adhesions around the right atrium, cardiopulmonary bypass was established between a 34F two-stage venous cannula (DLP, Inc, Grand Rapids, MI) in the right atrium and arterial return to the right femoral artery. Systemic cooling was initiated immediately. During the period of cooling, the heart was freed from the pericardial adhesions. After 35 minutes of cooling and when the temperature reached 23°C, the heart went into ventricular fibrillation. When the nasopharyngeal temperature reached 15°C, circulatory arrest was established and the brachiocephalic vessels with the old grafts were identified and carefully dissected free. The old graft was excised and the brachiocephalic vessels were divided at their takeoff from the aorta. After debris and atherosclerotic material were removed from the lumen of the vessels, an aorto-innominate artery side-to-end Gore-Tex (W. L. Gore & Associates, Flagstaff, AZ) No. 8 graft and an aorto-left subclavian/left carotid side-to-end bifurcated Gore-Tex No. 16 graft were placed. The proximal stump of the old graft was used for the proximal anastomosis of the latter. The left brachiocephalic vein was reconstructed with a Gore-Tex No. 10 interposition graft (Fig 1
). Aortocoronary bypass grafting to the right coronary artery with reversed saphenous vein graft was performed during rewarming. The cooling lasted 43 minutes, the circulatory arrest lasted 70 minutes, and the cardiopulmonary bypass time was 120 minutes. The mean aortic pressure ranged from 50 to 85 mm Hg throughout the procedure.
View larger version (159K):
[in this window]
[in a new window]
|
Fig 1. . Photograph and drawing illustrating the operation. There are four grafts: (1) bifurcated aorto-left subclavian/left carotid artery graft, (2) aorto-innominate artery graft, (3) left brachiocephalic vein interposition graft, and (4) aorto-right coronary artery saphenous vein graft. (A = aorta; LC = left common carotid artery; LS = left subclavian artery; RA = right atrium; RV = right ventricle; SVC = superior vena cava.)
|
|
The patient was extubated 24 hours after operation and, after an uncomplicated recovery, she was discharged from the hospital on the 8th postoperative day. Triplex studies carried out 8 months after the operation showed patent grafts.
|
Comment
|
|---|
Although more than a thousand cases of primary operation for brachiocephalic arterial stenoses and occlusions have been reported in the last 20 years [1–5], there are few data regarding management and outcome in redo cases. In this patient we thought that reconstruction was the treatment of choice because concomitant aorto-iliac disease precluded extraanatomic reconstruction with femoro-carotid or femoro-subclavian bypass.
Because of the risk of inadvertent damage to the previous graft lying immediately posterior to the sternum, the femoral artery was cannulated despite the known presence of diffuse aortoiliac disease. The femoral vein was exposed, but venous return was secured from the right atrium after uneventful resternotomy. The rationale for hypothermic circulatory arrest was to provide cerebral protection during an obligatory period of interruption of cerebral blood flow. Particular attention was paid to gentle handling of both the diseased native vessels and the previous graft to minimize the risk of cerebral embolism.
To ensure adequate cerebral perfusion during the cooling period, the mean arterial blood pressure was maintained between 50 and 85 mm Hg. In our patient it took 43 minutes of cooling to reach a nasopharyngeal temperature of 15°C, comparable with the 30 to 90 minutes of cooling reported in the literature [6]. The use of profound hypothermic circulatory arrest to produce uniform brain cooling even in the presence of unilateral and bilateral carotid artery stenoses is well documented [7] and may be explained on the basis of collateral blood flow and cerebral autoregulation. Indeed, the successful outcome in our patient supports the hypothesis that collateral flow and cerebral autoregulation remain intact even in the presence of severe occlusive disease of all the major cerebral blood vessels.
This case report illustrates that the presence of severe occlusive disease of the native brachiocephalic vessels and previous graft is not a contraindication to further attempts at reconstruction and that the use of profound hypothermic circulatory arrest provides satisfactory cerebral protection.
|
Footnotes
|
|---|
Address reprint requests to Dr Hadjinikolaou, Salton House, St Mary's Hospital, Praed St, London W2 1NY, England.
|
References
|
|---|
- Edwards WH, Mulherin JL Jr. Surgical reconstruction of the proximal subclavian and vertebral arteries. South Med J 1986;79:702–9.[Medline]
- Crawford ES, Stowe CL, Powers RW Jr. Occlusion of innominate, common carotid and subclavian arteries: long-term results of surgical treatment. Surgery 1983;94:781–91.[Medline]
- Schulz U, Laubach K, Preissler P. Reconstructive surgery for supraaortic occlusions-a report of 356 cases. Thoraxchir Vask Chir 1977;25:294–7.[Medline]
- Martsinkiavichius A, Triponis V, Barkauskas E. 10-year experience of surgical treatment of occlusive disease of the aorta and main arteries. Kardiologiia 1976;16:11–4.[Medline]
- Wylie EJ, Effeney DJ. Surgery of the aortic arch branches and vertebral arteries. Surg Clin North Am 1979;59:669–80.[Medline]
- Kirklin JW, Barratt-Boyes BG. Hypothermia, circulatory arrest and cardiopulmonary bypass. In: Kirklin JW, Barratt-Boyes BG, eds. Cardiac surgery, 2nd ed. New York: Churchill Livingstone, 1993:66–72.
- Kouchoukos NT, Daily BB, Wareing TH, Murphy SF. Hypothermic circulatory arrest for cerebral protection during combined carotid and cardiac surgery in patients with bilateral carotid artery disease. Ann Surg 1994;219:699–70.[Medline]
Top
Abstract
Introduction
