Ann Thorac Surg 2001;71:2027-2030
© 2001 The Society of Thoracic Surgeons
Case report
Hypothermic arrest for descending aortic rupture in reoperative patients
Edward M. Nadolny, CCPa,
Lars G. Svensson, MD, PhDa
a Center for Aortic Surgery, Department of Thoracic and Cardiovascular Surgery, Lahey Clinic, Burlington, Massachusetts, USA
Accepted for publication April 26, 2000.
Address reprint requests to Dr Svensson, Center for Aortic Surgery, Department of Thoracic and Cardiovascular Surgery, Lahey Clinic, 41 Mall Rd, Burlington, MA 01805
e-mail: lars.g.svensson{at}lahey.org
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Abstract
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Establishing hypothermic bypass for repair of descending thoracic aortic rupture in reoperative patients presents unique challenges for the operative team. A higher risk of stroke, embolization, and malperfusion further increases overall morbidity and mortality. Traditional femoral arterial cannulation may not be the optimal route for bypass for these patients. We report two reoperative cases using the right subclavian artery for arterial inflow to avoid these problems.
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Introduction
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Establishment of hypothermic cardiopulmonary bypass before opening the left chest for reoperative patients can be fraught with difficulty. Indeed, left thoracotomy with repair of the descending thoracic aorta has usually resulted in a high rate of death, stroke, or neurologic deficit [1–4]. To overcome these problems, we report a useful approach in two reoperative cases where we have used the right subclavian artery for arterial inflow.
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Case reports
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Patient 1
A 46-year-old man presented with an acute dissection of the distal arch and descending aorta. He complained of abdominal pain and had no right femoral pulse. Past medical history included an initial repair of a patent ductus arteriosus and later repair of an interrupted aortic arch between the innominate and left common carotid arteries in 1958.
Arteriography (Fig 1) showed a ruptured aortic dissection originating in the aortic arch between the innominate and left common carotid arteries, involving the left subclavian artery and extending distally to the iliac bifurcation. In addition, the distal true lumen was occluded by the septum (Fig 2). The celiac, superior mesenteric, and left renal arteries were perfused by the false lumen, and the right femoral true lumen was occluded.
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Fig 2. Abdominal aortogram through left false lumen. Note false lumen perfusing abdominal visceral arteries (upper arrow) and segment of occluded right femoral artery (lower arrow).
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The patient was positioned on his right side at about 30 degrees, with his arm by his side, allowing access to the right subclavian artery (Fig 3). There was no pulse in the right femoral artery, and the measured mean pressure was 45 mm Hg. The right subclavian artery was exposed, and then the left chest was opened and the fourth rib excised; however, the lung was not fully mobilized. After heparinization, the right subclavian artery was cannulated with an 18F cannula. The right femoral vein was cannulated with a 21F cannula advanced to the right atrium, and the right femoral artery was cannulated with a 14F angiocatheter.
During hypothermic circulatory arrest, the patient was placed in a slightly head-up position to prevent the heart from filling with air, and the flow was reduced through the subclavian artery to 300 mL/min. In addition, carbon dioxide was run into the surgical field at a flow rate of 10 L/min. The aortic arch was replaced with a 26-mm tube graft. After completion of the anastomosis and clamping of the graft, flow through the right subclavian arterial cannula was reestablished. The distal anastomosis was performed in the descending aorta; the patient was rewarmed and weaned from cardiopulmonary bypass. The circulatory arrest time was 25 minutes, and the cardiopulmonary bypass time was 168 minutes. The patient had no postoperative complications and was discharged on postoperative day 6.
Patient 2
A 30-year-old man with a history of two previous repairs for coarctation of the aorta presented with acute onset of hemoptysis. Arteriography revealed a descending aortic aneurysm and dilation of the old knitted graft, with involvement of the left subclavian artery and transverse arch and a constricted prior primary interposition bypass graft (Fig 4).
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Fig 4. Arteriogram of aneurysm shows knitted graft (white arrow) and primary constricted interposition graft (black arrow). Note contrast filling of some airways.
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The operative procedure was similar to that used in the first case, except a 10-mm tube graft was anastomosed end-to-side to the right subclavian artery because of poor exposure of the subclavian artery in a muscular person. In order to occlude flow to the descending aorta during performance of the distal anastomosis, a 28-mm graft was anastomosed to the distal aortic arch and onto the left subclavian artery with a balloon catheter inserted into the old 10-mm interposition coarctation graft. The bypass time was 157 minutes, and the circulatory arrest time was 28 minutes. The patient had an uneventful recovery, was discharged on day 7, and had no neurocognitive deficit.
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Comment
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Reoperative descending thoracic aortic surgery with aortic rupture can be challenging. Because of adhesions, the aorta cannot be readily controlled. Therefore, the patient must be cooled before exposure of the aorta in case complete exsanguination occurs upon entering the chest. The ability to use a variety of neuroprotective techniques and cannulation options, such as the right subclavian artery, is critical. In the presence of aortic dissection, care must be taken to ensure that perfusion of the true lumen and viscera is also accomplished. Inadvertent malperfusion of the false lumen can result in the septum’s acting as a flutter valve, with inadequate perfusion of the upper body and brain if the femoral arteries are used.
The potential for air embolization is always of great concern. In the reoperative patient, adhesions can prevent adequate removal of air from the heart, and open anastomotic techniques leave the vasculature in direct communication with room air. Carbon dioxide field flooding and low-flow antegrade perfusion minimize the likelihood of air embolization and may reduce neurocognitive deficits related to air accumulation in the heart, including after minimal-access surgery [5]. Because of the additional time needed to manipulate the catheters, we did not place any occlusion catheters in the great vessels to allow for antegrade brain perfusion in these 2 patients, but we have done so with other patients [6].
Previous studies have reported the high risk of stroke and neurologic deficit with hypothermic circulatory arrest through left thoracotomy [1–4]. Safi and associates [1] reported the results of 21 patients undergoing left thoracotomy and circulatory arrest. The mortality rate was 29% overall and 50% for emergent operations. Encephalopathy occurred in 5 patients (33%), stroke in 2 (13%), and spinal chord neurologic deficit in 2 (13%). Ergin and associates [2]—in a review of 200 patients undergoing circulatory arrest for operations on the thoracic aorta, with a 15% mortality rate and an embolic stroke rate of 11%—found that descending thoracic aortic repairs had a greater risk of neurologic complications. Svensson and associates [3], in a review of 656 patients undergoing deep hypothermia and circulatory arrest, also found that patients with repairs involving the descending thoracic aorta had more complications.
The technique we describe appears to reduce the occurrence of neurologic deficit and stroke, especially because the risk of air embolization is not as great and because malperfusion is avoided by use of the right subclavian artery for arterial inflow.
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References
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Safi H.J., Miller C.C., III, Subramanian M.H., et al. Thoracic and thoracoabdominal aortic aneurysm repair using cardiopulmonary bypass, profound hypothermia, and circulatory arrest via left side of the chest incision. J Vasc Surg 1998;28:591-598.[Medline]
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Ergin M.A., Galla J.D., Lansman S.L., Quintana C., Bodain C., Griepp R.B. Hypothermic circulatory arrest in operations on the thoracic aorta. J Thorac Cardiovasc Surg 1994;107:788-799.[Abstract/Free Full Text]
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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 1993;106:19-31.[Abstract]
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Kieffer E., Koskas F., Walden R., et al. Hypothermic circulatory arrest for thoracic aneurysmectomy through left-sided thoracotomy. J Vasc Surg 1994;19:457-464.[Medline]
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Svensson L.G., D’Agostino R.S. Minimal-access aortic and valvular operations, including the "J/j" incision. Ann Thorac Surg 1998;66:431-435.[Abstract/Free Full Text]
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Svensson L.G., Hussain A., Penney D.L., et al. A prospective randomized study of neurocognitive function and S-100 protein after antegrade or retrograde brain perfusion with hypothermic arrest for aortic surgery. J Thorac Cardiovasc Surg 2000;119:163-166.[Free Full Text]
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Abstract
Introduction
