| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Ann Thorac Surg 2004;78:1838-1839
© 2004 The Society of Thoracic Surgeons
a Department of Cardiothoracic Surgery, Staffordshire, United Kingdom
b Department of Anesthesia, University Hospital of North Staffordshire NHS Trust, Staffordshire, United Kingdom
Accepted for publication July 21, 2003.
* Address reprint requests to Dr Loubani, Department of Cardiothoracic Surgery, University Hospital of North Staffordshire NHS Trust, Princess Rd, Hartshill, Stoke-on-Trent, Staffordshire ST4 7LN, UK.
mahmoud.loubani{at}ntlworld.com
 |
Abstract |
|---|
 Top Abstract IntroductionCommentReferences |
|---|
|
Introduction |
|---|
|
TopAbstractIntroductionCommentReferences |
|---|
A 63-year-old man was referred for aortic valve replacement for grade æ aortic regurgitation. He had been having chest pain mimicking myocardial infarction, but without cardiac enzyme rise or electrographic changes. Coronary angiography demonstrated a significant stenosis proximally in the left anterior descending artery. The ascending aorta was dilated and demonstrated a false lumen with sluggish flow in it raising the suspicion of chronic aortic dissection. Computed tomographic scan demonstrated a 7.7 cm ascending aorta with type A dissection. There was also extensive arteriosclerosis of the abdominal aorta, iliac, and femoral arteries
After standard anesthesia, a median sternotomy was performed and the left internal mammary artery was mobilized. The right saphenous vein was dissected from the groin, and a 6 cm length was harvested from the terminal end of the vein at the saphena-femoral junction. The right axillary artery was then dissected using the standard technique [1] through a subclavicular incision. A side biting clamp was applied to the axillary artery and the saphenous vein was anastomosed to a longitudinal arteriotomy using a continuous 5-0 Prolene suture (Ethicon, Somerville, NJ) (Fig 1). Two 4-0 Prolene purse strings (Ethicon) were then inserted at the distal end of the vein graft and a 22 French arterial perfusion cannula (Life Stream International Inc, The Woodlands, TX) was inserted into the vein graft and secured in place using a snugger that was then tied to the cannula as seen in Figure 2. No tissue glue was used at the anastomosis site. Venous return was established through a two-stage cannula into the right atrium. Cardiopulmonary bypass was established and the patient cooled to 28°C. Flows of 5 L/min were achieved throughout the operation. The arterial line pressure throughout bypass was satisfactory. Antegrade cold blood cardioplegia was administered through the coronary ostia with topical cooling to arrest the heart. Further intermittent cardioplegia was administered at 30 minutes intervals. After the completion of the aortic valve repair and replacement of the ascending aorta, cardiopulmonary bypass was discontinued uneventfully. The vein graft was flush ligated with a suture.
|
|
|
Comment |
|---|
|
TopAbstractIntroductionCommentReferences |
|---|
In order to avoid damage to the artery, as well as to allow for perfusion of the right arm during surgery, we did not use direct cannulation of the axillary artery. This becomes all the more important with prolonged operations as the arm is not only affected by the direct ischemic injury, but subsequent reperfusion may result in damage due to compartment syndrome [4].
The use of a prosthetic graft, whether it be the woven double velour (Hemashield Gold) [4] or the Gorr-Tex [5], avoids direct cannulation of the axillary artery, but this raises a number of issues. The suture line of the graft to the axillary artery may not be hemostatic and allows continuous leakage of blood during the operation, which require continuous suction through a pump sucker resulting in hemolysis. Tissue glue can also be used to reduce this, but it is not cost effective. Other complications such as wound hematoma, false aneurysm, and infection are rare but well known among cardiac surgeons.
In our technique as previously described, the use of a length of saphenous vein avoids the possible complications from the use of prosthetic grafts. In addition to being much more hemostatic it comes "free" and is readily available. The cost of a prosthetic graft ranges from $800 to $900 in the United Kingdom. Given the overall cost of the procedure, the additional expense of the prosthetic graft may appear insignificant. If used in large numbers, the expenses will be significant. Better hemostasis with a saphenous vein (as in our case) needs to be evaluated in a larger series.
The vein should be harvested near the saphena-femoral junction. Although we did not have any problem in inserting the size 22 French cannula, the size of the vein may be an issue, especially in small women. Preoperative assessment of the caliber of vein by ultrasound may be helpful.
It may be argued that the groin has to be operated on with this method. However, this in fact allows for exposure of the femoral vessels at the same time and enables immediate access for cardiopulmonary bypass as a last resort. This also allows for the insertion of an intraaortic balloon pump, if required, at the termination of the cardiopulmonary bypass. Extra precautions should be taken to avoid complications such as lymphatic fistulas and contamination of the graft.
|
References |
|---|
|
TopAbstractIntroductionCommentReferences |
|---|
This article has been cited by other articles:
|
|
 |
|
  H. Gulbins, A. Pritisanac, and J. Ennker Axillary Versus Femoral Cannulation for Aortic Surgery: Enough Evidence for a General Recommendation? Ann. Thorac. Surg., March 1, 2007; 83(3): 1219 - 1224. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. Iglesias, P. Jungebluth, O. Sibila, I. Aldabo, M. P. Matute, C. Petit, A. Torres, and P. Macchiarini Experimental safety and efficacy evaluation of an extracorporeal pumpless artificial lung in providing respiratory support through the axillary vessels J. Thorac. Cardiovasc. Surg., February 1, 2007; 133(2): 339 - 345. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
