Ann Thorac Surg 2006;81:1916-1917
© 2006 The Society of Thoracic Surgeons
How to do it
Aortic Cannulation Through the Aneurysm for Repair of Thoracoabdominal Aortic Aneurysms
Hiroyuki Kamiya, MD
*
,
Maximiliam Pichlmaier, MD,
Axel Haverich, MD,
Matthias Karck, MD
Division of Thoracic and Cardiovascular Surgery, Hannover Medical School, Hannover, Germany
Accepted for publication March 7, 2005.
* Address correspondence to Dr Kamiya, Division of Thoracic and Cardiovascular Surgery, Hannover Medical School, Carl-Neuberg-Strasse 1, Hannover, 30625 Germany (Email: hkamiya88{at}yahoo.co.jp).
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Abstract
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We hereby present our experiences with arterial cannulation through the aneurysm in patients with thoracoabdominal aortic aneurysm. This can be a good option for thoracoabdominal aortic aneurysm repair in patients with diseased peripheral arteries.
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Introduction
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Cardiopulmonary bypass (CPB) is a safe and established technique for distal perfusion support during operations for thoracoabdominal aortic aneurysm (TAAA) [1]. With this technique, femoral cannulation is normally used; however, it is difficult to perform this procedure for patients with peripheral arterial disease or vascular prostheses that are already placed at the femoral artery. We hereby present our experiences with arterial cannulation through the aneurysm in patients with TAAA.
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Technique
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Access to the thoracoabdominal aorta is provided by lateral thoracotomy, transection of the costal margin, circular division of the diaphragm, and subsequent retroperitoneal preparation. After systemic heparinization, the arterial cannula is inserted into the aneurysm. At first the cannula is cautiously advanced through the mural thrombus. After arterial backflow is flushed through the cannula, it is advanced 1 cm further, flushed again, and fixed snugly by using normal pursestring sutures (Fig 1) (Fig 2). The venous cannula is inserted into the pulmonary artery after partial pericardiotomy. Then CPB is initiated to maintain distal perfusion, and mild hypothermia at 34°C is induced. The thoracic aorta is transected between occlusion clamps, and a proximal anastomosis is carried out. Then the distal clamp is moved down to the level of the diaphragm before the aorta is incised longitudinally. Intercostal arteries are reattached to the graft and reperfused after the translocation of the proximal clamp. With the release of the distal clamp, CPB is discontinued. The aneurysm is opened and the arterial cannula is removed. Selective visceral perfusion is established with oxygenated blood. Depending on the individual anatomy, direct reimplantation of these vessels into the vascular prosthesis is performed. In general, the right renal artery is reimplanted into a separate opening in the dorsal side of the prosthesis, and the left renal artery together with the celiac trunk and superior mesenteric artery is reimplanted in one island in the anterolateral side of the prosthesis. Then the graft is anastomosed above or on the aortic bifurcation. Finally, CPB is resumed with the perfusion cannula directly reinserted into the graft, and the patient is rewarmed.
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Fig 1. Patient with a Crawford type I aneurysm. The diaphragm is mobilized circumferentially (arrow) and the aneurysmatic abdominal aorta is cannulated for arterial access, slightly proximal of the origin of the left renal artery.
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Comment
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Between January 2001 and December 2004, 58 patients had surgical repairs of TAAA using CPB in our hospital. Among this population, 5 patients had the arterial cannulation through the aneurysm to initiate CPB. Three patients had Crawford extent I aneurysm, 1 patient had extent II, and another had extent IV. All the patients were men aged 71 ± 6 years (range, 63 to 80 years). Three patients had previously received aorto-femoral "Y"-bypass grafting and 2 had severe peripheral arterial disease in the common iliac artery. The average duration of CPB and aortic cross clamping were 177 ± 81 and 113 ± 45 minutes, respectively. There were no complications related to the arterial cannulation to establish CPB. There were no in-hospital deaths, and no patient suffered from paraplegia. No patient had embolic events in lower extremities. Postoperative complications were respiratory failure in 1 patient and bleeding in another.
Cannulation of the femoral artery and vein represents a standard technique for the surgical repair of TAAA [1]. However, in patients with severe peripheral arterial disease at the iliac or femoral artery, this approach may be not advisable. Another cohort whose groin cannulation should be used reluctantly (due to an increased infectious risk) are patients with vascular prosthesis in the femoral artery. Kunitomo and colleagues [2] reported an arterial cannulation at the non-aneurysmal descending aorta in a patient with Crawford extent III TAAA and obstruction of the distal aorta, but this can only be applied to Crawford type III and IV TAAA, and the ischemia time of the spinal cord may be critical because sequential cross clamping is impossible.
We believe that this is the first report that presents aortic cannulation through the aneurysm for TAAA repair. With this technique, the potential risk of emboli due to spreading of mural thrombus may be a concern, but we have not experienced such complications. In addition, the possible complications related to the inguinal wound and the femoral artery can be avoided. At present, we do not aim to enlarge the indication of this cannulation technique for patients with normal peripheral arteries, but this can be a good option for TAAA repair in patients with diseased peripheral arteries.
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References
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- Coselli JS. The use of left heart bypass in the repair of thoracoabdominal aortic aneurysms Semin Thorac Cardiovasc Surg 2003;15:326-332.[Medline]
- Kunitomo R, Goto H, Utoh J, Kitamura N. Thoracoabdominal aortic aneurysm combined with aortic occlusion Ann Thorac Surg 2000;69:623-625.[Abstract/Free Full Text]
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Abstract
Introduction
