Ann Thorac Surg 1996;62:1208-1209
© 1996 The Society of Thoracic Surgeons
How To Do It
Transpericardial Inferior Vena Caval Cannulation in Thoracic Aorta Operations
Eugenio Neri, MD,
Dominique Maiza, MD,
Olivier Coffin, MD,
Massimo Massetti, MD
Thoracic and Cardiovascular Department, University Hospital, Caen, France
Accepted for publication June 10, 1996.
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Abstract
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Surgical treatment of thoracic aneurysms is frequently performed with the aid of partial cardiopulmonary bypass. When profound hypothermia and circulatory arrest are employed, inadequate venous drainage may represent a major problem. We herein describe a technique of inferior vena caval cannulation that allows steady performance when high pump flows are imposed.
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Introduction
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Posterolateral thoracotomy and thoracoabdominal incisions are the exposures of choice for the treatment of thoracic aorta aneurysm. The replacement of segments of the descending aorta through these exposures is frequently performed with the aid of partial cardiopulmonary bypass. The adjunct of profound hypothermia and circulatory arrest may offer some advantages in terms of hemodynamic stability, technical flexibility, spinal cord and viscera protection, and operative comfort [1–5]; on the other hand, it requires high pump flows and optimal venous drainage.
Venous drainage of cardiopulmonary bypass is classically obtained by a cannula introduced in the right atrium through the femoral vein. Inadequate venous drainage (because of the small caliber of the cannulas), difficulty in getting over the iliocaval junction or reaching right atrium (because of a collapsed inferior vena cava), and interruption of limb venous flow are some of the common problems encountered with this technique [4, 5].
Percutaneous wire-guided insertion techniques and new design cannulas are now available. They obviate some of the drawbacks of femoral vein cannulation, but they do not always guarantee adequate performance. Alternative venous cannulation sites have been proposed, to allow high pump outputs [4]. Right ventricular cannulation through the pulmonary trunk allows good venous return [3, 5] but has some disadvantages [4]. In case of a large aneurysm it can be difficult to achieve optimal pulmonary artery exposure; furthermore, this kind of cannulation exposes the patient to the risk of pulmonary artery and pulmonary valve damage, and to pulmonary artery stenosis after removal of cannulas. This kind of cannulation also does not offer optimal operative comfort, because the venous cannula is across the operative field during the procedure.
Left external iliac vein [2] and left renal vein cannulation [4] are additional options: the former imposes an additional left lower quadrant incision for a retroperitoneal approach, and the latter is feasible only in the case of thoracoabdominal exposure.
We describe herein the technique of transpericardial inferior vena caval cannulation that we use in thoracic aorta operations. It is performed through posterolateral thoracotomy and thoracoabdominal incisions with the aid of cardiopulmonary bypass, profound hypothermia, and circulatory arrest.
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Technique
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If a left posterolateral thoracotomy approach is chosen, this is made through the fifth or sixth intercostal space, the left lung is collapsed, and the pericardium is incised vertically, posterior to the left phrenic nerve. The incision is enlarged dorsally along the diaphragmatic reflection of the pericardium. The pulmonary ligament is divided, and the preesophageal pericardium and the pericardial reflection of the inferior vena cava are cut (Fig 1
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Fig 1. . Intrathoracic path toward inferior vena cava (IVC). (ESOPH. = esophagus; L. = left; N = nerve.)
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Additional mobilization can be obtained by liberating the inferior vena cava across the diaphragm. Care must be paid not to open the right pleura, because a large quantity of blood can gather in the right pleural cavity during the procedure.
The anterior free edge of the pericardium is suspended with a stay suture, and the heart is gently pulled cranially while the diaphragm is lowered. This exposes the inferior vena cava, and a 3-0 Ticron pursestring suture is performed, large enough to enable the insertion of a 32F to 36F right-angled cannula into the right atrium (Fig 2). Some space must be left between the pursestring suture and the right atrium to avoid lesions of the coronary sinus.
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Fig 2. . Intraoperative aspect of inferior vena caval exposure through left thoracotomy. (CS = coronary sinus; D = diaphragm; E = esophagus; IVC = inferior vena cava; L = lung; PR = pericardial reflection.)
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To facilitate the insertion of the cannula, two fine monofilament stay sutures can be placed inside the pursestring area, allowing enough counterpulsion for the insertion of the cannula. They are very useful when the inferior vena cava is small or collapsed, avoiding traction on the pursestring. The rationale for placing the stay sutures inside the area of the pursestring is to prevent any laceration of the inferior vena cava caused by the stay sutures from becoming a major problem at decannulation.
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Comment
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Since 1993 we have performed transpericardial inferior vena caval cannulation in 23 operations on the descending aorta for extensive aneurysm. In all 23 patients transpericardial inferior vena caval cannulation was easy to perform and no complication was encountered. In 2 cases it was not possible to employ this technique because of previous sternotomy and subsequent pericardial adhesions.
The proposed technique represent a viable alternative to the traditional techniques, allows excellent venous drainage, and, in spite of its demanding appearance, is not difficult to perform. Nevertheless, the extensive posterior pericardial opening and the depth and limited area of the operative field require a thorough knowledge of the region, cautious dissection, and attentive identification of the structures. Transpericardial inferior vena caval cannulation is particularly indicated when profound hypothermia and circulatory arrest are considered for replacement of segments of the descending aorta.
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Footnotes
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Address reprint requests to Dr Neri, Thoracic and Cardiovascular Department, University Hospital, Avenue Cote de Nacre 14033, Caen, France.
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References
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- Livesay JJ, Cooley DA, Ventemiglia RA, et al. Surgical experience in descending thoracic aneurysmectomy with or without adjuncts to avoid ischemia. Ann Thorac Surg 1985;39:37–46.[Abstract]
- Carlson DE, Karp RB, Kouchoukos NT. Surgical treatment of aneurysms of the descending thoracic aorta: an analysis of 85 patients. Ann Thorac Surg 1983;35:58–69.[Abstract]
- Kouchoukos NT, Wareing TH, Izumoto H, Clausing W, Abboud N. Elective hypothermic cardiopulmonary bypass and circulatory arrest for spinal cord protection during operations on the thoracoabdominal aorta. J Thorac Cardiovasc Surg 1990;99:659–64.[Abstract]
- Kieffer E, Godet G, Koskas F, et al. Chirurgie des anevrysmes de l'aorte thoracique descendante et thoraco-abdominale:techniques et indications de la perfusion aortique distale. In: Fichelle JM, ed. Techniques et strategie en chirurgie vasculaire. Paris: AERCV, 1991:109–38.
- Kazui T, Komatsu S, Yokoyama H. Surgical treatment of aneurysms of the descending thoracic aorta with the aid of partial cardiopulmonary bypass: an analysis of 95 patients. Ann Thorac Surg 1987;43:622–7.[Abstract]
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Abstract
Introduction
