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Ann Thorac Surg 1999;68:294
© 1999 The Society of Thoracic Surgeons

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Correspondence

Left superior vena cava in a distal arch aneurysm: could it be of any advantage?

^a Cardiothoracic Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India

To the Editor

Retrograde cerebral perfusion has been used as an adjuvant in the cerebral protection of patients who have complex aneurysm operations [1, 2]. However, the conventional approach of posterolateral thoracotomy for distal arch aneurysms makes retrograde cerebral perfusion difficult. The coexistence of a left superior vena cava could provide an opportunity to administer retrograde cerebral perfusion in a distal arch aneurysm from this approach.

A 34-year-old man had a large aneurysm involving the distal aortic arch, distal to the origin of the left common carotid artery and involving the origin of the left subclavian artery. Cardiopulmonary bypass was established by cannulating the descending thoracic aorta with a 20-F aortic cannula (Baxter Research Medical Inc, Midvale, UT) and pulmonary artery with a 36-F angled venous cannula. The patient was cooled to 18°C and total circulatory arrest was attained. The left superior vena cava, which had been dissected, was canulated using an angled 20-F venous cannula, and retrograde cerebral perfusion was commenced to achieve a maintenance flow of 500 mL per minute, maintaining the pressure around 20 mm Hg. After interposing a Gelseal graft (Vascutek-Sulzer Medica, Renfrewshire, Scotland, United Kingdom) for the distal arch aneurysm, the perfusion was restarted from the descending aortic cannula, and cardiopulmonary bypass was reestablished. The patient was rewarmed to 37°C and gradually weaned off cardiopulmonary bypass. The patient was awake after 6 hours and was weaned off the ventilator after 14 hours. The cardiopulmonary bypass time was 140 minutes, and the total circulatory arrest time was 35 minutes.

The coexistence of the left superior vena cava in a distal arch aneurysm might be advantageous, as it provides an opportunity for retrograde cerebral perfusion from a posterolateral thoracotomy. The only disadvantage is that the left superior vena cava crossing the aneurysm makes the exposure of the aneurysm a little difficult. If it obscures the aneurysm, one should not hesitate to transect the left superior vena cava and reconstruct it once the aneurysm is repaired.

References

1. Safi H.J., Brien H.W., Winter J.N., et al. Brain protection via cerebral retrograde perfusion during aortic arch aneurysm repair. Ann Thorac Surg 1993;56:270-276.[Abstract]
2. Svensson L.G., Crawford E.S., Hess K.R., et al. Deep hypothermia with circulatory arrest—determinants of stroke and early mortality in 656 patients. J Thorac Cardiovasc Surg 1992;106:19-31.[Abstract]

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Anil Bhan Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Bhan, A. Articles by Venugopal, P. Search for Related Content PubMed Articles by Bhan, A. Articles by Venugopal, P.