Ann Thorac Surg 1999;67:1815-1816
© 1999 The Society of Thoracic Surgeons
How to Do It
Retrograde cerebral perfusion for aortic operations through left thoracotomy
Sandro Bartoccioni, MDa,
Carlo Massini, MDa,
Paolo Fiaschini, MDa,
Gino Di Manici, MDa,
Corrado Fedeli, MDa,
Davide Di Lazzaro, MDa
a Department of Cardiac Surgery, Azienda Ospedaliera di Perugia, Ospedale Silvestrini, Perugia, Italy
Accepted for publication December 22, 1998.
Address reprint requests to Dr Bartoccioni, Department of Cardiac Surgery, Ospedale "R. Silvestrini", S. Andrea delle Fratte, 06156 Perugia, Italy
e-mail: mc0315{at}mclink.it
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Abstract
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Retrograde cerebral perfusion during deep hypothermic circulatory arrest is a technique used largely during operations on the ascending aorta, aortic arch, or both through a median sternotomy. This method is not frequently used for operations performed through a left thoracotomy because of problematic access to the right side of the heart. We propose a technique allowing retrograde cerebral perfusion through a left thoracotomy in a quick, simple, and efficient manner.
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Introduction
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Use of retrograde cerebral perfusion during deep hypothermic circulatory arrest for operations on the thoracic aorta through a left thoracotomy is rare. This is because access to the superior vena cava is difficult with a left thoracotomy approach. One way around this problem is to cannulate the superior vena cava through a second incision in the neck. Recently, Yamashita and colleagues [1] proposed a method of retrograde cerebral perfusion during operations on the distal aortic arch through a posterolateral thoracotomy. After the patient was placed in the Trendelenburg position to achieve a central venous pressure of 15 mm Hg, the femoral venous cannula was used to deliver blood retrograde to the brain. We propose a different method to deliver retrograde cerebral perfusion by way of the superior vena cava during operatios through a left thoracotomy.
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Technique
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The pericardium is opened with a longitudinal incision 4 cm above the left phrenic nerve during cooling. Stay sutures are tied to the upper border of the thoracotomy to rotate and raise the superior vena cava above the ascending aorta. Coupled with gentle medial traction on the ascending aorta, the stay sutures provide good exposure of the superior vena cava. This allows placement of a 7-F cannula into the vena cava above the azygos vein for cardioplegia (Fig 1). The cannula is connected to a pressure transducer and to the arterial line of the pump by means of a Y connector. The connector is opened at the beginning of hypothermic circulatory arrest, thus allowing the oxygenated blood to go retrograde to the brain; the arm of the arterial line going to the femoral artery is clamped. At the same time, the superior vena cava between the cannula and the azygos vein is clamped.
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Fig 1. View of operative field from patient’s left side after placement of stay sutures to lift the pericardium. (A = superior vena cava; B = cannula for cardioplegia; C = clamp; D = ascending aorta; E = left lung.)
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In addition, at the start of retrograde cerebral perfusion, we inflate two pressure cuffs, previously placed on the arms, to a pressure a little higher than the infusion pressure of the retrograde cerebral perfusion, which is kept at 15 to 18 mm Hg [2]. This produces a somewhat selective cerebral perfusion and avoids the unnecessary retrograde perfusion of the arms.
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Comment
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Our technique is an effective, simple way to accomplish retrograde cerebral protection by way of the superior vena cava through a left thoracotomy. Our method offers the same advantages as by the median sternotomy approach. These include selective perfusion into the superior vena cava upstream from the azygos vein with no backflow into the right atrium (there is no experimental proof supporting superiority of selective superior vena cava perfusion versus atrial or inferior vena cava perfusion, as the latter also produces retrograde cerebral perfusion through collaterals), control of perfusion pressure, quasi-selective retrograde perfusion of the brain with oxygenated cold blood, and washout of air bubbles and debris from the brachiocephalic arteries.
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References
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Yamashita C., Okada M., Yoshimura T., et al. Impact of retrograde cerebral perfusion with posterolateral thoracotomy on distal arch aneurysm repair. Ann Thorac Surg 1998;65:955-960.[Abstract/Free Full Text]
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Bartoccioni S, Massini C, Fiaschini P, et al. Simple method to improve the effectiveness of brain retrograde perfusion during total circulatory arrest. J Cardiac Surg 1997;12:201. J Thorac Cardiovasc Surg 1997;113:810–1.
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Abstract
Introduction
