| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
a Division of Cardiothoracic, Emory University, Atlanta, Georgia
b Division of Vascular Surgery, Emory University, Atlanta, Georgia
Accepted for publication July 6, 2007.
* Address correspondence to Dr Long, Emory University, Division of Cardiothoracic Surgery, 2880 Alpine Rd, Atlanta, GA 30305-3404 (Email: smlong3{at}yahoo.com).
 |
Abstract |
|---|
 Top Abstract IntroductionCase ReportsCommentReferences |
|---|
|
Introduction |
|---|
|
TopAbstractIntroductionCase ReportsCommentReferences |
|---|
|
Case Reports |
|---|
|
TopAbstractIntroductionCase ReportsCommentReferences |
|---|
The patient was taken immediately to the operating room for ascending aortic and hemiarch replacement using right axillary artery arterial cannulation and selective cerebral antegrade perfusion under hypothermic circulatory arrest (HCA) and mitral replacement. The lack of Doppler signals in the lower extremity persisted after cardiopulmonary bypass. Axillobifemoral bypass grafting was constructed with lower extremity fasciotomies.
The patient’s postoperative recovery was notable for rhabdomyolysis, renal failure, and a cerebral infarct. Immediate intensive care unit (ICU) creatine kinase levels exceeded 16,000 U/L and remained at 11,000 U/L by postoperative day (POD) 6. Initial myoglobin levels exceeded 4000 ng/mL. The patient was discharged on POD 30 to a rehabilitation center, requiring dialysis. He had excellent neurologic recovery during the ensuing weeks, and renal function ultimately returned.
Patient 2
A 23-year-old man presented with chest pain radiating to the back. The initial TEE noted an ATAD with an aortic root aneurysm and 2+ aortic regurgitation. A CT scan showed no contrast filling the iliac vessels. Physical examination revealed cold lower extremities with no palpable pulses or Doppler signals. The admission creatinine level was 1.4 mg/dL.
The patient underwent ascending aortic and hemiarch replacement as well as a David V valve-sparing root replacement with right axillary artery arterial cannulation and selective cerebral antegrade perfusion under HCA. After CPB, lower extremity malperfusion and cyanosis persisted. Axillobifemoral bypass grafting was performed to restore lower extremity perfusion.
Postoperatively, creatine kinase levels rose to almost 40,000 U/L, and myoglobin levels exceeded 4000 ng/mL. The left thigh required fasciotomies, muscle débridement, and ultimately, skin grafting. Renal failure required temporary dialysis. The patient recovered to be discharged to a rehabilitation center, with recovery of renal function.
Patient 3
A 45-year-old man with a history of hypertension presented with acute chest pain and cool lower extremities. Physical examination revealed absence of pulses or Doppler signals. The right leg was without sensation, but the left leg had motor and sensory function. A CT scan revealed ATAD with no contrast flow below the aortic bifurcation. The admission creatinine level was 1.6 mg/dL, and the creatine kinase level was 121 U/L. TEE showed 4+ aortic regurgitation with normal left ventricle function and an intimal flap in the ascending aorta. As previously described [3, 4], both femoral arteries were exposed during right axillary artery exposure before sternotomy in preparation for performing axillobifemoral bypass grafting pre-CPB. The distal femoral anastomoses were constructed with a prefabricated axillobifemoral bypass graft concurrently with Dacron (DuPont, Wilmington, DE) graft anastomosis to the axillary artery. Both grafts were cannulated using a bifurcated arterial line, thereby establishing separate inflow for the upper body and lower extremities.
Sternotomy was then performed and CPB was initiated. Ascending aortic and hemiarch replacement under HCA and selective cerebral antegrade perfusion was performed as well as aortic valve resuspension. After CPB, the axillobifemoral polytetrafluoroethylene (PTFE) graft was anastomosed to the Dacron graft of the right axillary artery, thus restoring normal lower extremity pulsatile inflow.
The patient’s postoperative creatinine level peaked at 1.8 mg/dL and was 1.3 mg/dL at discharge. His creatine kinase levels peaked at 1500 U/L 12 hours postoperatively. Immediate postoperative myoglobin levels were 800 ng/mL and 500 ng/mL by POD 1. The patient’s initial acidosis cleared after 48 hours, at which time he was extubated with completely intact lower extremity function. The patient was discharged home on POD 12.
Patient 4
A 51-year-old man presented with abdominal, upper back, and chest pain. The patient’s right leg was cool and without sensation below the knee. Motor function was intact. There were no Doppler signals in the right lower extremity, but the left pulses were intact. A CT scan showed an ATAD and no contrast opacifying the right iliac artery.
Intraoperative TEE showed 2+ aortic regurgitation in the setting of an aortic root aneurysm. Owing to the extremity malperfusion, both femoral vessels were exposed simultaneously during right axillary artery exposure. An 8-mm PTFE graft was used to construct a femorofemoral bypass during anastomosis of a Dacron graft to the right axillary artery for arterial perfusion. Sternotomy was performed and CPB commenced after right atrial cannulation, thus perfusing both lower extremities. ATAD repair included a David V valve-sparing root replacement. After CPB, distal pulses were present in both lower extremities.
Postoperatively, the patient was extubated in a timely fashion with intact lower extremity motor and sensory function. The ICU admission creatine kinase level was 400 U/L and peaked at 1500 U/L on POD 1. Initial ICU myoglobin level was 1012 ng/mL and declined to 800 ng/mL by POD 1. The creatinine level was 1.0 mg/dL at admission, initially peaked at 2.2 mg/dL on POD 4, and recovered without hemodialysis. A persistent loculated left hemothorax developed, which required drainage on POD 16 using video-assisted thorascopic surgery. The patient was discharged home on POD 25 with a creatinine level of 1.5 mg/dL.
|
Comment |
|---|
|
TopAbstractIntroductionCase ReportsCommentReferences |
|---|
It is unclear whether femoral artery cannulation would have avoided the issue of renal failure. Because its etiology was felt to be secondary to rhabdomyolysis from lower extremity reperfusion and not a primary ischemic insult during operation, in all likelihood, renal failure would have occurred no matter which site was chosen for arterial cannulation. Femoral cannulation with retrograde aortic perfusion has the inherent potential complications of embolization, retrograde extension, and visceral malperfusion in ATAD. The advantages of axillary cannulation include antegrade arterial perfusion during CPB as well as during deep HCA with potential lower neurologic morbidity [5], and it is our preferred site for arterial access.
Lower extremity revascularization before ATAD repair can be done with simultaneous exposure of groin vessels during right axillary artery exposure and sternotomy. Minimal operative time is an added benefit if performed in conjunction with a peripheral vascular team. Lower extremity revascularization is tailored to either an axillobifemoral or femorofemoral bypass, depending on whether perfusion to one or both extremities is compromised. Lower extremity revascularization before CPB minimizes lower extremity ischemia and allows for initial reperfusion in a more favorable hypothermic condition compared with delayed normothermic reperfusion that occurs when revascularization is performed after ATAD repair. This strategy is potentially beneficial in not only increasing the salvage rate of limb function but also decreasing the need for dialysis in rhabdomyolysis-induced renal failure after ATAD repair in patients presenting with peripheral vascular malperfusion.
|
References |
|---|
|
TopAbstractIntroductionCase ReportsCommentReferences |
|---|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 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 |
