Ann Thorac Surg 2005;79:e36-e38
© 2005 The Society of Thoracic Surgeons
Case report
Transaxillary Aortic Endoclamping for Ascending Aortic Pseudoaneurysm and Dissected Descending Aorta
Daniele Maselli, MD*,
Francesco Musumeci, MD
Department of Cardiac Surgery, Azienda Ospedaliera S. Camillo-Forlanini, Rome, Italy
Accepted for publication March 25, 2004.
* Address reprint requests to Dr Maselli, Divisione di Cardiochirurgia, Azienda Ospedaliera S. Camillo-Forlanini, Circonvallazione Gianicolense 87, 00152 Rome, Italy (E-mail: dmaselli{at}tiscali.it).
 |
Abstract
|
|---|
Patients presenting with pseudoaneurysm of the aortic root close to the sternum, severe aortic regurgitation, and chronic dissection of the descending aorta represent a formidable surgical challenge. Closed chest circulatory arrest in this setting carries a high risk of myocardial or brain damage. We propose a modification of the port-access technique that allows control and access of the pseudoaneurysm, avoiding the need for closed chest circulatory arrest. Our strategy is based on transaxillary endoclamping of the ascending aorta and combines the advantages of antegrade aortic flow with the possibility of stopping the heart and venting the left ventricle before sternotomy.
|
Introduction
|
|---|
The combination of pseudoaneurysm of the ascending aorta, severe aortic regurgitation, previous surgery for acute aortic dissection, and residual false lumen in the descending aorta is a challenging situation to manage. The risk of exsanguination or myocardial and brain damage is high even with transaxillary cardiopulmonary bypass and circulatory arrest before sternotomy. We report clinical use of a new strategy based on the port-access techniques that allows simultaneous antegrade pump flow into the aorta, endoclamping of the ascending aorta, and administration of cardioplegia before sternotomy.
|
Technique
|
|---|
A 60-year-old woman had ascending aortic replacement with a 28-mm allograft for acute type A aortic dissection. She was referred to our institution in November 2001, 37 months later, when echocardiography revealed an ascending aortic pseudoaneurysm and severe aortic regurgitation. A computed tomography scan showed a 6-cm pseudoaneurysm of the aortic root expanding anterior and laterally from the proximal suture line and a chronic dissection of the descending aorta with a partially thrombosed false lumen. Angiography demonstrated disruption of the proximal allograft suture line and a normal-sized aortic arch with unobstructed flow to the upper limbs.
At operation left and right radial artery and central venous pressures were monitored. Under transesophageal echo guidance an EndoPlege catheter (Heartport, Redwood City, CA) was placed through the right internal jugular vein for retrograde cardioplegia delivery. The right femoral vein was cannulated with a 25F QuickDraw venous cannula (Heartport, Redwood City, CA). The right axillary artery was exposed. An 8-mm Dacron (C.R. Bard, Covington, GA) graft, trimmed at a 45° angle to provide a bigger surface for easier advancement and withdrawal of the endoaortic balloon, was anastomosed to the ventral aspect of the axillary artery by continuous 6-0 polypropylene suture. A 23F EndoReturn arterial cannula (Heartport) was inserted into the Dacron graft, secured with three ties, and connected to the arterial line. A guidewire was advanced under echo guidance into the side branch of the arterial cannula, the Dacron graft, and the axillary artery, down to the ascending aorta and into the left ventricle. An EndoClamp aortic catheter (Heartport) was then advanced through the same route and positioned at the level of the ascending aortic allograft. Cardiopulmonary bypass was started with vacuum-assisted venous return (Fig 1).
View larger version (39K):
[in this window]
[in a new window]
|
Fig 1. The perfusion circuit. The venous cannula is inserted into the right atrium through the right femoral vein. Venous drainage is vacuum assisted. Arterial return (AL) is into the right axillary artery. Blood cardioplegia can be delivered through the aortic root via the endoclamp catheter (EC) or into the coronary sinus via the retrograde cardioplegia catheter (RCC). (VAVD = vacuum-assisted venous drainage.)
|
|
At 32°C the aorta was endoclamped (Fig 2) and blood retrograde cardioplegia administered; the big lumen of the endoclamp was used to vent the ascending aorta and left ventricle. Transesophageal echocardiography and radial artery pressure monitoring was used to evaluate eventual displacement of the aortic balloon [1]. A median sternotomy was performed and after dissection of adhesions, the pseudoaneurysm was accessed with minimal blood loss. The ascending aortic allograft was isolated and clamped, then the endoclamp was deflated and withdrawn into the aortic arch. A dehiscence of the proximal suture between the aorta and the allograft was observed. The aortic root was replaced with a 25-mm St. Jude composite graft. At 28°C circulation was arrested, the cross-clamp was removed, and the old allograft was completely resected; no entry ports were observed up to the aortic isthmus. The new graft was anastomosed to the ventral portion of the aortic arch; after a short period of washout retrograde cerebral perfusion, circulation was restarted. Circulatory arrest time was 13 minutes. Before tying the suture, the deflated endoclamp was positioned into the new ascending aortic conduit to allow removal of air during weaning from cardiopulmonary bypass. The patient was rewarmed and the operation was completed in the usual fashion. The 8-mm Dacron graft used to access the axillary artery was tied and divided. The patient was extubated after 20 hours and was discharged after 10 days. No complications were observed. The patient was alive and well at 2 years’ follow-up.
View larger version (104K):
[in this window]
[in a new window]
|
Fig 2. Transesophageal long axis view of the aortic root. The endoclamp (EC) is inflated into the ascending aortic allograft (AG), excluding the pseudoaneurysm (PS) from the circulation. (LA = left atrium.)
|
|
|
Comment
|
|---|
To minimize the risk of catastrophic exsanguination and brain damage, pseudoaneurysms of the ascending aorta are usually approached under hypothermic circulatory arrest. Femorofemoral cannulation is used to start cardiopulmonary bypass and cooling before sternotomy. Closed-chest circulatory arrest, however, can be dangerous in the presence of severe aortic regurgitation as, even if a left ventricular vent is placed through the apex through a small left thoracotomy, the procedure can be ineffective in preventing ventricular distension.
A technique of aortic endoclamping based on the port-access technique [2, 3] for control of ascending aortic pseudoaneurysms, as reported by D’Attelis and associates [4] and Pettersson and colleagues [5], has proven to be reliable and safe. In the dissected descending aorta, however, retrograde flow carries a risk of malperfusion or brain embolism. The management we propose allows antegrade flow into the aorta, maintained perfusion of the right upper limb during cardiopulmonary bypass, closed-chest clamping of the ascending aorta and avoidance of the deleterious affects of aortic regurgitation, administration of cardioplegia, and left ventricular venting before sternotomy. Potential fields of application of this technique are limited to special situations in which a pseudoaneurysm of the aortic root and severe aortic regurgitation are associated with diseased descending aorta. In cases in which the descending aorta is normal, a standard transfemoral port-access approach can be used. Even in the absence of aortic regurgitation, as in the presence of a functioning aortic prosthesis, the technique can be advantageous to stop the heart before opening the chest whenever the risk of entering the pseudoaneurysm exists. Before planning the procedure it is necessary to document that the brachiocephalic trunk and axillary artery are not involved in the disease and that a natural or prosthetic endoclampable (not larger than 40 mm) aortic segment exists downstream of the entry port of the pseudoaneurysm itself. Good experience with standard port-access procedures is obviously essential. Costs are increased but, in our opinion, can be counterbalanced by the substantial advantage that the technique offers. Positioning of the endoclamp was slightly different from the usual port-access procedure. Because of the preformed curvature of the balloon and because the small curvature of the arch did not offer, in this particular case, enough length to support the balloon, left ventricular ejection caused migration of the balloon into the descending aorta during positioning and inflation. To overcome this problem we advanced the guidewire into the left ventricle during balloon positioning and we administered a bolus of adenosine (6 mg/mL, 2 mL) into the aortic root to stop the heart just after inflating the balloon. The endoclamp catheter could in theory be advanced through the aortic valve into the left ventricle to allow venting in cases in which an endoclampable aortic segment is not available, but the maximal amount of blood that can be vented through an endoclamp can be inadequate to face the amount of the regurgitant volume through the aortic valve.
Aortic endoclamping through the axillary artery should be considered as a good option for management of ruptured aortic root pseudoaneurysm in patients with a diseased descending aorta, to reduce the risk of a potentially life-threatening operation.
|
References
|
|---|
- Applebaum RM, Cutler WM, Bhardwaj N, et al. Utility of transesophageal echocardiography during port-access minimally invasive cardiac surgery Am J Cardiol 1998;82:183-188.[Medline]
- Schwartz DS, Ribakove GH, Grossi EA, et al. Minimally invasive cardiopulmonary bypass and cardioplegic arresta closed chest technique with equivalent myocardial protection. J Thorac Cardiovasc Surg 1996;111:556-566.[Abstract/Free Full Text]
- Stevens JH, Burdon TA, Peters WS, et al. Port-access coronary artery bypass graftinga proposed surgical method. J Thorac Cardiovasc Surg 1996;111:567-573.[Abstract/Free Full Text]
- D’Attelis N, Diemont FF, Julia PL, Cardon C, Fabiani JN. Management of pseudoaneurysm of the ascending aorta performed under circulatory arrest by port-access Ann Thorac Surg 2001;71:1010-1011.[Abstract/Free Full Text]
- Pettersson G, Nores M, Gillinov AM. Transfemoral control of ruptured aortic pseudoaneurysm at aortic root operation Ann Thorac Surg 2004;77:311-312.[Abstract/Free Full Text]
This article has been cited by other articles:
|
|
|
|
 
K. G. Reyes, G. B. Pettersson, T. Mihaljevic, and E. E. Roselli
A strategy for safe sternal reentry in patients with pseudoaneurysms of the ascending aorta using the PORT-ACCESS EndoCPB system
Interactive CardioVascular and Thoracic Surgery,
November 1, 2009;
9(5):
893 - 895.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. Maselli, G. Santise, A. Montalto, and F. Musumeci
Endovascular Aortic Clamping for Pseudoaneurysms of the Aortic Root With Aortic Regurgitation
Ann. Thorac. Surg.,
October 1, 2005;
80(4):
1303 - 1308.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
