Ann Thorac Surg 1999;67:597-598
© 1999 The Society of Thoracic Surgeons
Correspondence
Pericardial lift facilitates central cannulation in left anteroaxillary thoracotomy
Shiro Sasaguri, MDa,
Tomonobu Fukuda, MDa,
Yasuyuki Hosoda, MDa
a Department of Thoracic Cardiovascular Surgery, Juntendo University, 2-1-1 Hongo Bunkyo-ku, Tokyo, 113 Japan
e-mail: sasaguri{at}med.juntendo.ac.jp
We have advocated the use of a left anteroaxillary thoracotomy as an alternative approach for aortic arch reconstruction [1, 2]. This type of thoracotomy combines the advantages of each approach while filling the gap between a median sternotomy and a posterolateral thoracotomy by providing a wide view of the aortic arch from the ascending aorta to the mid-descending aorta and allowing accessibility to the superior vena cava (SVC) for retrograde cerebral perfusion during deep hypothermic circulatory arrest.
Recently, a few surgeons who have adopted this type of thoracotomy for arch reconstruction have raised some issues regarding exposure of the ascending aorta and the SVC (Sakamoto T, personal communications September 1998). In their cases, involving an elongated ascending aorta or aneurysmally dilated aorta, central cannulation from the ascending aorta or venous drainage from the SVC could not be performed through the anteroaxillary thoracotomy because the right side of the ascending aorta was hidden behind the sternum, and the SVC was not accessible because of the elongated aorta.
To obtain better exposure of the SVC and the ascending aorta through an anteroaxillary thoracotomy, there are a few tactics, in our experience, that can be useful. First, the pericardial stitch, which is placed at the corner of the pericardial reflection on the SVC, can raise the SVC and pull out the ascending aorta toward the operative field, thus facilitating aortic and SVC cannulation (Fig 1). Second, direct SVC cannulation should be performed after the establishment of cardiopulmonary bypass. Low, nonpulsatile arterial pressure may make direct cannulation easier. Finally, transecting the sternum may be the last choice to obtain further exposure of the ascending aorta and the SVC. However, this method seems to be invasive and requires refixing the sternum [3]. In our experience, the former two techniques may more easily resolve any difficulties that accompany exposure of the ascending aorta and SVC through a left anteroaxillary thoracotomy.
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Fig 1. Pericardial lift (arrow) facilitates aortic (Ao) and superior vena caval (SVC) cannulation in left anteroaxillary thoracotomy. (An = arch aneurysm; H = heart; L = lung; RA = right atrium.)
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References
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Sasaguri S., Yamamoto S., Fukuda T., Hosoda Y. Anteroaxillary thoracotomy facilitates the use of retrograde cerebral perfusion in distal aortic arch reconstruction. Ann Thorac Surg 1996;62:1861-1862.[Abstract/Free Full Text]
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Sasaguri S., Yamamoto S., Fukuda T., Hosoda Y. Retrograde cerebral perfusion through antero-axillary thoracotomy in the aortic arch surgery. Eur J Cardiothorac Surg 1997;11:657-660.[Abstract]
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Westaby S., Katsumata T. Proximal aortic perfusion for complex arch and descending aortic disease. J Thorac Cardiovasc Surg 1998;115:162-167.[Abstract/Free Full Text]
