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Ann Thorac Surg 2006;81:1112-1114
© 2006 The Society of Thoracic Surgeons
a Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
b Peachtree Vascular Associates, Atlanta, Georgia
Accepted for publication February 7, 2005.
* Address correspondence to Dr Chen, Division of Cardiothoracic Surgery, Emory University School of Medicine, 1365 Clifton Rd NE, Suite 2236, Atlanta, GA 30322 (Email: edward_chen{at}emoryhealthcare.org).
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Abstract |
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Introduction |
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A 28-year-old man was the unrestrained driver of a rollover motor vehicle crash. He was unresponsive at the accident scene, but later awoke neurologically intact. In the emergency room of his local hospital, he was hemodynamically stable and initially complained of chest pain. A chest roentgenogram showed bilateral first rib fractures and a widened mediastinum. Thoracic aortography demonstrated transection of the transverse aortic arch distal to the innominate artery with a large surrounding hematoma and no evidence of flow in the left common carotid artery (Fig 1). Additional evaluation, including an abdominal and pelvic computed tomographic scan, head computed tomographic scan, and cervical spine computed tomographic scan demonstrated no other injuries. A chest computed tomographic scan performed at the time of abdominal imaging confirmed the presence of the mid-transverse arch transection and left common carotid artery avulsion, as well as a left hemothorax. The patient was transferred to Emory Crawford Long Hospital on a continuous esmolol infusion for definitive treatment of his aortic injury.
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The patient's intact mental status despite lack of left carotid arterial flow on aortography prompted additional evaluation with carotid duplex ultrasound to assess for any antegrade flow in order to determine whether revascularization would be indicated. This demonstrated a non-occluding thrombus in the proximal portion of the left common carotid artery with evidence of antegrade flow in both the left external and internal carotid arteries. Laboratory studies were only significant for a blood alcohol level of 222 mg/dL and a urine toxicology screen positive for cocaine.
A standard median sternotomy incision was performed to gain access to the ascending aorta and transverse arch. Arterial cannulation for cardiopulmonary bypass was performed using an 8-mm Dacron graft (Gelweave; Vascutek Inc, Ann Arbor, MI) sewn end-to-side to the right axillary as well as direct cannulation of the left femoral artery. A single pump head was used for arterial perfusion and a branched circuit tubing was connected by a "Y" to both the right axillary artery graft and the left femoral artery. Systemic pressure was monitored using both a radial arterial as well as a right femoral arterial catheter. The patient was cooled systemically and selective antegrade cerebral perfusion was initiated through the right axillary artery when the patient reached 18°C. Myocardial protection was maintained with continuous retrograde cold blood cardioplegia through a coronary sinus catheter and intermittent antegrade cardioplegia administered directly into the coronary ostia. The innominate artery was occluded proximally and antegrade cerebral perfusion was carried out at 10 mL/kg/min and adjusted to maintain a mean perfusion pressure of 50 to 60 mm Hg through the right radial arterial line. The aorta was opened and inspection of the transverse arch showed a complete circumferential transection immediately distal to the origin of the innominate artery. A large hole in the mid-arch was noted where the left common carotid artery had been completely avulsed. Distal to these injuries, the left subclavian artery was intact. In addition, there was a large hematoma involving most of the ascending aorta. The aortic arch was excised and a number 26 Gelweave graft (Vascutek USA Inc, Ann Arbor, MI) was sewn to the distal aortic arch at the level of the subclavian artery with a running 4–0 Prolene suture (Ethicon, Somerville, NJ). The innominate artery was reimplanted to an 8-mm side arm in the Gelweave graft (Vascutek USA Inc) with a running 5–0 Prolene suture (Ethicon). The air was removed from the arterial tree, the patient was placed on cardiopulmonary bypass, and rewarming was started. Circulatory arrest time was 47 minutes.
Because preoperative carotid duplex demonstrated antegrade flow in the left system, an additional 8-mm side arm graft was sewn onto the Gelweave graft (Vascutek USA Inc). A separate incision was made anterior to the left sternocleidomastoid muscle. The graft was subsequently tunneled into the left neck and anastomosed end-to-end to the left common carotid artery. The ascending aorta was excised down to the sinotubular junction. The proximal aorta graft anastomosis was completed with a running 4–0 Prolene suture (Ethicon). Cross-clamp time was 91 minutes. After rewarming and air removal, the patient was weaned from cardiopulmonary bypass with minimal inotropic support. Total cardiopulmonary bypass time was 195 minutes.
The patient awoke neurologically intact and was extubated on postoperative day 1. He was transferred out of the intensive care unit on postoperative day 3 and was discharged home on postoperative day 6 after an uneventful hospital recovery.
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Comment |
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Because of the rarity of combined injury to the ascending aorta, aortic arch, and arch vessels, management of this injury combination has not been fully defined. A variety of cannulation, perfusion, and neuroprotective strategies may be potentially used for repair of aortic arch injuries.
Axillary artery cannulation has become an acceptable and widely used technique of aortic cannulation for surgery involving the ascending aorta and aortic arch and allows for antegrade perfusion during cardiopulmonary bypass, with minimal associated morbidity [3]. In this patient, the pressure gradient across the transected aortic arch and concern for potential malperfusion of the lower body with axillary artery cannulation alone necessitated the use of both axillary and femoral artery cannulation. In fact, prior to initiating femoral artery perfusion, axillary cannulation alone had resulted in a 10°C difference in the nasopharyngeal and bladder temperatures.
Selective antegrade cerebral perfusion is an effective method of neuroprotection during hypothermic circulatory arrest and can be safely used for extended periods of time during complex arch reconstruction [4]. This particular strategy has been shown to be a more effective means of preventing ischemic brain damage than retrograde cerebral perfusion or hypothermia alone [5]. Although potentially cumbersome, the use of axillary artery cannulation combined with simple occlusion of the innominate artery provides a simple means of antegrade cerebral perfusion during circulatory arrest [3].
The majority of complex injuries to the ascending aorta and aortic arch are lethal and rarely reach medical attention. In patients who can tolerate surgery and systemic heparinization, immediate repair can be safely performed using axillary artery cannulation, profound hypothermic circulatory arrest with selective antegrade cerebral perfusion.
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This article has been cited by other articles:
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  J. EV, G. Mundayat, K. Chunduru, J. Abraham, A. Palliyil, and D. Perimpa Delayed surgery for traumatic rupture of aortic arch with dissection of the left anterior descending artery. J. Thorac. Cardiovasc. Surg., February 1, 2008; 135(2): 428 - 430. [Full Text] [PDF]
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