Ann Thorac Surg 2001;72:1744-1746
© 2001 The Society of Thoracic Surgeons
Case report
Reoperation for interrupted aortic arch with the use of retrograde cerebral perfusion
Naoki Yoshimura, MD*a,
Masahiro Yamaguchi, MDa,
Yoshihiro Oshima, MDa,
Shigeteru Oka, MDa,
Yoshio Ootaki, MDa
a Department of Cardiothoracic Surgery, Kobe Children’s Hospital, Kobe, Japan
Accepted for publication December 21, 2000.
* Address reprint requests to Dr Yoshimura, Department of Cardiothoracic Surgery, Kobe Children’s Hospital, 1-1-1, Takakura-dai, Suma-ku, Kobe, 654-0081 Japan
e-mail: y-naoki{at}za2.so-net.ne.jp
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Abstract
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We treated 2 patients with recurrent coarctation after repair of interrupted aortic arch. Because they had been operated on with the use of vascular prostheses, severe scarring was considered prohibitive for safe dissection. We successfully carried out anatomic repair with the use of retrograde cerebral perfusion through a left thoracotomy in both cases.
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Introduction
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Recurrent coarctation after repair of interrupted aortic arch presents a formidable technical challenge with hazard for the patient. The type of initial repair, degree of intrathoracic scarring, length of aortic narrowing, collateral vessel status, and protection of the brain and spinal cord during aortic cross-clamping must be considered [1]. A single method of operation is not applicable in all patients, and the surgeon must be flexible in selecting a technique designed to meet each patient’s requirements. In the presence of severe scarring or anomalous arch vessels, extraanatomic bypass is sometimes used to avoid dangerous dissection and clamping [2, 3]. Recently, we performed anatomic repair with the use of retrograde cerebral perfusion (RCP) through a left lateral thoracotomy [4, 5] in 2 patients with recurrent coarctation after repair of interrupted aortic arch.
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Case reports
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Patient 1
The patient was a 14-year-old boy who was born with interrupted aortic arch type A and ventricular septal defect. At 15 days of age he underwent the Blalock-Park procedure (turndown of the divided left subclavian artery onto the decsending aorta in an end-to-end fashion) and pulmonary artery banding. He required patch graft aortoplasty with the use of a woven Dacron vascular prosthesis 21 months later for residual coarctation. At 2 years of age, he had closure of the ventricular septal defect and pulmonary artery reconstruction. His postoperative course was uneventful until hypertension developed at age 13 years. On physical examination, his blood pressure was 170 mm Hg and arm-leg pressure gradient was 60 mm Hg. Preoperative aortogram showed recurrent coarctation between an area just distal of the left common carotid artery and the prosthetic patch graft (Fig 1A). A pressure gradient of 35 mm Hg was found at catheterization. He underwent unsuccessful percutaneous transluminal balloon angioplasty and had a reoperation at 14 years of age.
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Fig 1. Aortogram in case 1. (A) Preoperative aortogram showed recurrent coarctation (white arrow) between just distal of the left common carotid artery and the prosthetic patch graft. The distal segment of left subclavian artery can be seen with retrograde filling (black arrow). (B) Postoperative aortogram showed a smooth contour of the vascular graft.
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The operation was done through a left lateral thoracotomy. The common femoral artery was cannulated, and a venous cannula was inserted from the common femoral vein into the right atrium. Cardiopulmonary bypass (CPB) was instituted with left atrial venting. Adhesions between the chest wall and lung were divided, and the descending thoracic aorta and vagal nerve were dissected precisely during cooling by CPB. After the rectal temperature decreased to 23°C, the patient was placed in the Trendelenburg position to keep the central venous pressure at 10 to 15 mm Hg. During a brief period of circulatory arrest, the descending aorta was clamped proximal to the arterial cannula and the distal aortic arch was incised. Femorofemoral bypass was restarted at a flow rate of 1.0 L/m2 per minute, and blood cardioplegia was infused by way of an occlusion catheter passed retrograde through the open arch and placed in the ascending aorta. The high central venous pressure in the Trendelenburg position with the aortic arch open caused the oxygen-rich venous blood to perfuse the brain tissue retrogradely from the right atrium to the arch vessels [4, 5]. The temperature of the perfused blood during RCP was maintained at 17°C to 18°C. During the RCP period, proximal anastomosis of the 22-mm vascular graft and native aorta was done without clamping the aortic arch. When the surgical procedure was disturbed by effluent blood passing through the head vessels, RCP flow was reduced to 0.3 L/m2 per minute. After the proximal anastomosis was completed, an arterial cannula was inserted into the side branch of the vascular graft, and antegrade perfusion of the brain and heart was initiated from a supplementary circuit. Rewarming was started at a flow rate of 2.4 L/m2 per minute. The prosthetic patch graft was resected, and distal anastomosis was done during rewarming by CPB. Total perfusion time, RCP time, and low-flow RCP time were 244 minutes, 62 minutes, and 13 minutes, respectively. He showed clear consciousness and had no neurologic complications postoperatively. Although compartment syndrome developed in the left lower leg caused by femoral cannulation, he showed gradual recovery in a few days. Postoperative aortogram showed a smooth contour of the vascular graft (Fig 1B). The pressure gradient between ascending aorta and descending aorta decreased to 4 mm Hg.
Patient 2
The patient was a 14-year-old girl who was born with interrupted aortic arch type B and ventricular septal defect. At 2 months of age she had aortic arch reconstruction with a woven Dacron vascular graft 8 mm in diameter followed by pulmonary artery banding at 3 months of age. At 4 years of age, she underwent closure of the ventricular septal defect and pulmonary artery reconstruction. Gradually, the arm-leg blood pressure gradient increased, and reoperation was considered. Preoperative aortogram showed recurrent coarctation between the left common carotid artery and the left subclavian artery. There was a pressure gradient of 26 mm Hg between the ascending aorta and descending aorta at catheterization. Graft replacement with a vascular prosthesis 18 mm in diameter was done in the same way as described for case 1. Because the common femoral artery was hypoplastic, an arterial cannula was inserted into the descending aorta to prevent lower limb ischemia. When the surgical procedure was disturbed by effluent blood passing through the head vessels, total circulatory arrest was used during the period of open proximal anastomosis. Total perfusion time, RCP time, and circulatory arrest time were 270 minutes, 38 minutes, and 16 minutes, respectively. She showed clear consciousness and had no neurologic complications postoperatively. Postoperative aortogram showed a smooth contour of the vascular graft, and there was no pressure gradient between ascending aorta and descending aorta at catheterization.
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Comment
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In these 2 patients who had been operated on with vascular prostheses, severe scarring was considered prohibitive for safe dissection. It was also necessary to avoid clamping the aortic arch because the stenotic lesion was just distal of the left common carotid artery in both cases. Some surgeons prefer extraanatomic bypass in such cases [2, 3]. We carried out anatomic repair with the use of RCP through a left thoracotomy according to the method that Takamoto and associates [4, 5] described. Retrograde cerebral perfusion is a well-known technique of brain protection during aortic arch operation in adults and is used widely with satisfactory results [6]. Retrograde cerebral perfusion is a simple technique that does not need special equipment, cannulation, or clamping of the arch vessels. Although RCP is not a substitute for normal brain perfusion, it can reduce ischemic damage of the brain by providing blood flow [7]. Also it can flush out air in the cerebral vessels and maintain the desired cerebral temperature by cooling the perfused blood [7].
There is widespread distribution of the collateral vessels in patients with recoarctation. Effluent blood passing through the collateral vessels disturbed the operative field during RCP in our patients. Temporary total circulatory arrest or low-flow RCP was useful. Usually, the femoral artery was hypoplastic in patients with recoarctation. The hypoplastic femoral artery was occluded easily by an arterial cannula, which might have caused lower limb ischemia during CPB. Insertion of an arterial cannula into the descending aorta was useful in preventing lower limb ischemia during CPB.
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References
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Abstract
Introduction
