Ann Thorac Surg 1999;67:874-875
© 1999 The Society of Thoracic Surgeons
How To Do It
Cannulation of the supraceliac aorta for perfusion in small infants
Akira Mishima, MDa,
Miki Asano, MDa,
Shigeki Yamamoto, MDa,
Takayuki Saito, MDa,
Tadao Manabe, MDa
a Division of Cardiovascular Surgery, Nagoya City University Medical School, Nagoya, Japan
Accepted for publication August 31, 1998.
Address reprint requests to Dr Mishima, Division of Cardiovascular Surgery, Nagoya City University Medical School, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601, Japan
e-mail: mishima{at}med.nagoya-cu.ac.jp
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Abstract
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Because the usual arterial cannulation was not possible, two small infants successfully underwent cardiovascular operation with an arterial cannula in the supraceliac aorta through the gastrohepatic ligament for cardiopulmonary bypass. Follow-up 2.5 years after operation revealed no morbidity. Cannulation of the supraceliac aorta is unusual but should be considered as a valuable surgical option in special cases such as ours.
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Introduction
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In neonates and infants with congenital heart defects, the site of arterial cannulation for cardiopulmonary bypass is usually the ascending aorta or main pulmonary trunk. Retrograde cannulation from an iliac or femoral artery is acceptable as an alternative approach in children [1]; however, it seems not to be indicated in small infants at risk for resultant complications, such as damage and obstruction. Therefore, we positioned the arterial cannula in the supraceliac aorta through the gastrohepatic ligament to institute cardiopulmonary bypass in a neonate and a small infant. The neonate required cannulation of the supraceliac aorta for separate perfusion of the lower body, and the infant required it for uncontrollable bleeding from the ascending aorta. In this report, we describe the technique and results of this cannulation.
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Material and methods
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Two patients underwent cardiovascular operation by cannulation of the supraceliac aorta for cardiopulmonary bypass at our institute in December 1995. Follow-up 2.5 years after operation revealed no morbidity of the cardiovascular, central nervous, or alimentary systems.
Patient 1
A 2-day-old neonate weighing 3 kg with an interrupted aortic arch type A presented with a life-threatening condition caused by closure of the ductus arteriosus. Venous administration of prostaglandin E1 was ineffective in reopening the duct, resulting in severe hepatic and renal failure. Because there was no choice but to manage the patient by inotropic support, mechanical ventilation, and peritoneal dialysis, he was referred to our hospital. He successfully underwent an emergency one-stage repair, including direct anastomosis of the arch and closure of the ventricular septal defect with the use of circulatory arrest. The closed duct required separate perfusion of the upper and lower half of the body to facilitate cooling and to protect the damaged organs. Therefore, an arterial cannula was inserted in both the ascending and supraceliac aorta. Peritoneal dialysis was performed uneventfully from postoperative days 1 to 5.
Patient 2
A 1-month-old infant weighing 3.9 kg presented with severe pulmonary stenosis after an arterial switch operation of transposition of the great arteries at 6 days of age. The patient underwent relief of pulmonary stenosis. However, uncontrollable bleeding occurred from the ascending aorta and innominate artery when the arteries were dissected from their dense adhesion to the surrounding structures. Cardiopulmonary bypass was initiated by cannulation of the supraceliac aorta because the usual arterial cannulation was considered impossible to perform. Pulmonary stenosis was successfully relieved using a xenopericardial patch after repair of the damaged arteries (Figure 1, 2).
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Fig 1. Sternotomy and anterior incision of the diaphragm provide good access to the aortic hiatus in the diaphragm through the gastrohepatic ligament without an extended abdominal incision. Division of muscle fibers above the hiatus in the midline exposes the supraceliac aorta.
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Fig 2. A nylon tape around the distal thoracic aorta is retracted caudad. An arterial cannula held by forceps is inserted through the stab wound within a single pursestring suture. Another forceps gripping the adventitia close to the incision is used to control any bleeding.
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Operative technique
A median sternotomy incision is extended caudad to a middle point between the xiphoid process and the umbilicus. After opening the pericardium and the peritoneum, the diaphragm is cut posteriorly to its fibrous position. The left triangle ligament is divided, and the gastrohepatic ligament is widely opened. After reflection of the left lobe of the liver to the right and retraction of the esophagus and the stomach to the left over a wet swab, an incision in the posterior peritoneum exposes the aortic hiatus in the diaphragm. Division and separation of the preaortic fibers of the diaphragm in the midline provide good exposure of the supraceliac aorta. The aorta is encircled with nylon tape and is retracted caudad. The cannula is inserted directly through a stab incision within a single pursestring suture. After cardiopulmonary bypass, the peritoneum and the diaphragm are closed without communication between the pericardial and peritoneal cavities. An intraperitoneal drainage tube is unnecessary.
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Comment
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In infants and neonates, the following alternative methods of arterial cannulation for perfusion have been reported: transapical aortic perfusion during cardiac operation [2] and carotid artery perfusion with extracorporeal membrane oxygenation [3]. However, these methods as well as retrograde cannulation from an iliac artery seem unsuitable for managing small infants who are unable to receive the usual arterial cannulation. The approach through the gastrohepatic ligament to the distal thoracic aorta has been used in clamping the aorta of a ruptured abdominal aneurysm, aortovisceral artery grafting, and extraanatomic bypass grafting of an obstruction of the aorta [4, 5]. We applied this approach to cannulation of the supraceliac aorta for cardiopulmonary bypass in two small infants. Sternotomy and anterior incision of the diaphragm provided excellent access to this region of the aorta without a standard abdominal incision. Cannulation of the supraceliac aorta is unusual but should be considered as a valuable surgical option in special cases such as ours. A potential disadvantage of this technique is the risk of biliary tract dysfunction resulting from division of the hepatic branches of the vagus nerve in the gastrohepatic ligament when it is fully opened. However, a 2.5-year follow-up of the patients revealed no morbidity, suggesting that our technique had little if any adverse effect on biliary tract function. However, longer-term follow-up will be needed to determine its usefulness in the growing child.
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References
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Salerno T.A., Lince D.P., White D.N., Lynn R.B., Charrette E.J. Arch versus femoral artery perfusion during cardiopulmonary bypass. J Thorac Cardiovasc Surg 1978;76:681-684.[Abstract]
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Pedersen T.H., Videm V., Svennevig J.L., et al. Extracorporeal membrane oxygenation using a centrifugal pump and a servo regulator to prevent negative inlet pressure. Ann Thorac Surg 1997;63:1333-1339.[Abstract/Free Full Text]
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Wukasch D.C., Cooley D.A., Sandiford F.M., Nappi G., Reul G.J., Jr Ascending aorta-abdominal aorta bypass: indications, technique, and report of 12 patients. Ann Thorac Surg 1977;23:442-448.[Abstract/Free Full Text]
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Cooley D.A. Abdominal (infrarenal) aorta. In: Cooley D.A., ed. Surgical treatment of aortic aneurysms. Philadelphia: WB Saunders, 1986:111-140.
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Abstract
Introduction
