Ann Thorac Surg 2008;85:1619-1624. doi:10.1016/j.athoracsur.2008.01.048
© 2008 The Society of Thoracic Surgeons
Original Articles: Adult Cardiac
Management of Intraoperative Malperfusion Syndrome Using Femoral Artery Cannulation for Repair of Acute Type A Aortic Dissection
Tomoki Shimokawa, MD*,
Shuichiro Takanashi, MD,
Naomi Ozawa, MD,
Tsuyoshi Itoh, MD
Department of Cardiovascular Surgery, Sakakibara Heart Institute, Tokyo, and Department of Thoracic and Cardiovascular Surgery, Saga University, Saga, Japan
Accepted for publication January 17, 2008.
* Address correspondence to Dr Shimokawa, Department of Cardiovascular Surgery, Sakakibara Heart Institute, 3-16-1 Asahicho, Fuchu City, Tokyo, 183-0003, Japan (Email: tshimokawa-circ{at}umin.ac.jp).
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Abstract
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Background: The site of cannulation for repair of ascending aortic dissection remains controversial. The objective of this study was to evaluate the incidence and management of intraoperative malperfusion syndrome using femoral cannulation for repair of acute type A aortic dissection.
Methods: Between May 2002 and February 2007, 107 patients with initial femoral artery cannulation for the repair of type A aortic dissection were enrolled in this study. The mean age was 63.7 ± 11.8 years; 51 patients were female. Preoperative findings indicated malperfusion in 16 patients. Intraoperative malperfusion syndrome was diagnosed by both radial arterial pressure measurements and transesophageal echocardiography. Clinical outcomes, including specific operative procedures and complications related to the cannulation, were assessed.
Results: The ascending aorta was replaced in 59 patients, hemiarch in 16, and total aortic arch in 32. Intraoperative malperfusion syndrome was noted in 3 patients (lowering of radial pressure in 2, obstruction of the true lumen in 1) at the initiation of cardiopulmonary bypass. After immediately switching to transventricular cannulation, the surgical replacement was successfully performed. The remaining 104 patients underwent surgery during femoral artery bypass without perfusion abnormalities. There was 1 in-hospital death (0.9%), but no deaths among the malperfusion patients. Cerebrovascular deficit occurred in 7 patients (6.5%). One vascular and 3 wound complications occurred related to the femoral cannulation.
Conclusions: During the repair of acute ascending aortic dissection, malperfusion syndrome related to femoral artery cannulation has an acceptable incidence, and can be managed under appropriate intraoperative monitoring, particularly at the initiation of cardiopulmonary bypass.
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Introduction
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Femoral cannulation has been used for cardiopulmonary bypass grafting since the 1950s [1], and the femoral artery is the primary site for arterial cannulation in treating type A aortic dissections. However, intraoperatieve malperfusion syndrome caused by inadequate retrograde perfusion is well known [2, 3]. Therefore, many surgeons prefer cannulating the axillary artery or central aorta instead of the femoral artery [4–8]. Nevertheless, axillary artery cannulation requires a more precise technique and is more time consuming than femoral cannulation. Furthermore, if the axillary artery is small, cardiopulmonary bypass flow might be insufficient. The disadvantage of transventricular cannulation is that repair of the aortic root and valve cannot be performed until the cannula is removed, and this can lead to significant aortic insufficiency when there is ventricular fibrillation [9–11].
It is also important to recognize and manage malperfusion syndrome during dissection repair. However, there have been few experimental studies on the management of intraoperative malperfusion syndrome. The objective of this study was to evaluate the incidence and management of intraoperative malperfusion syndrome using femoral cannulation for repair of acute type A aortic dissection.
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Material and Methods
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Between May 2002 and February 2007, surgical repair of acute type A aortic dissection was performed in 139 consecutive patients at Sakakibara Heart Institute. As a primary site for arterial cannulation, ascending aortic was used in 5 patients because the dissection limited the proximal ascending aorta and aortic root during the study period, and transventricular was used in 10 patients from January 2004 to September 2004. Femoral cannulation was initially performed in 107 of 124 patients, and these patients with initial femoral artery cannulation were enrolled in this study. The remaining 17 patients had femoral and axillar artery in 3 before 2003, and transventricular in 14 after 2004, because of distal arch aneurysm in 3, abdominal aortic aneurysm in 6, iliofemoral disease in 2, femoral artery dissection in 2, lower limb ischemia with leg pain in 3, and upper limb ischemia with neurologic symptoms in 1. Institutional Review Board approval was obtained for this study, and the Board waived the need for patient consent.
The arterial pressure of the both radial arteries and transesophageal echocardiography (TEE) were routinely monitored by a board-certified anesthesiologist and cardiologist. Particular attention was paid to the occurrence of intraoperative malperfusion syndrome and the need to change the cannulation site during the operation. When the cardiopulmonary bypass was started and the aorta was cross-clamped, we checked the arterial pressure of the both radial arteries, and evaluated for the area ratio of the true lumen and pseudolumen in the entire of descending aorta with TEE. The indications for switching to transventricular cannulation were that the arterial pressure was dropped or developed laterality, or the area of the true lumen in the descending aorta disappeared with TEE. In that case, femoral perfusion was stopped and was changed to transventricular. The cannula was passed through the apex and across the aortic valve until positioned in the ascending aorta. Perfusion was started, and the position of the cannula was verified again with TEE. The overall clinical outcome data including the cannulation site, specific operative repair, and complications related to cannulation were prospectively recorded in a database. The main endpoints were intraoperative malperfusion, neurologic and vascular complications, and death.
There were 56 male and 51 female patients with an average age of 63.7 ± 11.8 years (range, 29 to 86). Preoperative characteristics of the patients are presented in Table 1. At admission, 21 patients (19.6%) were in cardiogenic shock, with a systolic blood pressure of 80 mm Hg or less. Malperfusion was detected in 16 patients (15.0%); the site of the malperfusion was a coronary artery in 3, upper limb in 7, abdomen in 2, and lower limb in 6. Before the operation, 7 patients (6.5%) were intubated and 10 (9.4%) had drainage for cardiac tamponade. Preoperative and operative imaging showed that 33 patients (30.8%) had a thrombosed pseudolumen in the dissected aorta.
Our general technique included femoral artery and right atrium cannulation and perfusion during cardiopulmonary bypass. In most cases, the femoral artery was cannulated with either a 19.5F or 21F straight arterial cannula (Capiox-EB; Terumo, Tokyo, Japan) using the open-puncture technique, after placing a single 5-0 polypropylene pursestring suture and heparinization. The cannula was placed 4 to 5 cm into the artery and sutured to the skin. After evaluating the flow through the cannula by back-bleeding, it was connected to the cardiopulmonary bypass circuit. Most patients were cooled to a core body temperature of 22°C to 25°C. After aortic cross-clamping, the proximal aortic anastomosis was reinforced with Teflon felt strips and gelatin-resorcinol-formaldehyde glue. During hypothermic circulatory arrest and retrograde cerebral perfusion, a Dacron graft (Hemashield, Boston Scientific, Natick, MA; UB, Ube Medical, Tokyo, Japan; Intergard, Intervascular, La Ciotat, France) was sutured to the distal aortic arch. Antegrade systemic perfusion was then reinstituted through the side branch of the graft, and rewarming was started. Finally, the proximal anastomosis was completed. If a patient had an intimal tear in the aortic arch or distal arch, extended aortic arch replacement was performed using retrograde (n = 20, from April 2005 to July 2006) or antegrade cerebral perfusion (n = 13).
Statistical Analysis
All statistical analyses were performed using a statistical software program (SPSS, Chicago, Illinois). Continuous data were expressed as the mean ± SD. Univariate analysis was performed using Fisher's two-tailed exact test. Independent risk factors of intraoperative malperfusion were examined using a stepwise multiple logistic regression analysis. All p values less than 0.05 were taken as significant.
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Results
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Malperfusion Syndrome
The femoral artery was cannulated initially in 107 patients (71 right, 36 left). The ascending aorta was replaced in 59 patients, hemiarch in 15, and total aortic arch in 33. Concomitant procedures included coronary artery bypass in 5 patients, aortic root replacement in 6 (valve sparing in 4), and femorofemoral bypass in 2. The intraoperative times are shown in Table 2.
Malperfusion at the initiation of cardiopulmonary bypass was noted in 3 patients. In the first case, a 57-year-old man without malperfusion preoperatively had surgery 5.5 hours after the onset of dissection. The left femoral artery was used for cannulation. However, no pressure was observed in the right radial artery immediately after perfusion; therefore, the cannula was moved to the ascending aorta through the left ventricle. Cardiopulmonary bypass was completely established with no laterality, and there was sufficient pressure in the radial arteries. An intimal tear was present in the aortic arch, and total arch replacement was performed in the usual manner. In the second case, a 64-year-old woman, who had left lower limb ischemia without leg pain, was operated on 9 hours after the onset of aortic dissection. The right femoral artery was initially used for cannulation. However, TEE showed obstruction of the true lumen at the proximal descending aorta immediately after perfusion; therefore, the cannula was moved to the ascending aorta through the left ventricle (Fig 1). The cardiopulmonary bypass was sufficient, and ascending aortic replacement was performed as usual. In the third case, a 60-year-old man, who had no malperfusion preoperatively, had surgery 5.5 hours after the onset of aortic dissection. A preoperative computed tomography scan revealed thrombosis of the pseudolumen in the thoracic aorta and a double-barreled lumen in the abdominal aorta. The right femoral artery was used for cannulation. However, pressure in both radial arteries was low and high back pressure was noted in the arterial cannula despite changing of the location of the arterial cannula. Therefore, the cannula was moved to the ascending aorta through the left ventricle in this patient. The TEE showed no significant change of the thoracic aorta. Cardiopulmonary bypass was established again, and ascending replacement was performed as usual. Because the back pressure was equal to the radial arterial pressure before the initiation of bypass, we made the diagnosis of malperfusion syndrome. These 3 patients were discharged without complications and neurologic sequelae. Malperfusion on clamping of the aorta or on resumption of aortic flow was not seen in any patient.
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Fig 1. Transesophageal echocardiogram demonstrating the malperfusion at the proximal descending aorta in case 2. (A) Before bypass. (B, C) During the initiation of bypass; the area of the true lumen decreased and disappeared. (D) After switch of arterial cannulation and perfusion; the true lumen expanded and the blood flow became detectable. (T = true lumen, F = false lumen.)
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The adverse event rate in patients initially cannulated in the femoral artery was 2.8% in all patients (3 of 107), or 4.1% in patients with classical dissection that was defined as aortic dissection with flow in the false lumen (3 of 74). The remaining 104 patients underwent surgical replacement of the aorta with femoral cannulation and perfusion without perfusion abnormalities. Univariate and multivariate analysis did not identify any independent predictors of intraoperative malperfusion.
Morbidity and Mortality
There were 1 vascular and 3 wound complications related to femoral cannulation. An 86-year-old patient needed graft replacement of the femoral artery for injury caused by cannulation using a cut-down technique early in the series. Cerebrovascular deficit, defined as a permanent neurologic dysfunction, occurred in 7 patients. Four of 7 had documented episodes of loss of consciousness before arrival. Two patients presented with hemiplegia and the other was intubated preoperatively. Preoperative stroke was strongly suspected in these patients. Two of the remaining 3 patients had stroke 5 days and 13 days after surgery, respectively. The remaining patient had dissection into the arch branches, and a postoperative computed tomography scan revealed the obstruction at the anastomosis of the left common carotid artery after total arch replacement. The cause of cerebrovascular deficit might be associated with the technical problem. All of the complications in these patients cannot be attributed to intraoperative malperfusion or embolization. Other postoperative complications are shown in Table 3.
One in-hospital death (0.9%) occurred on postoperative day 8, as the result of preoperative cerebral infarction with a semicomatose state. We investigated closely and identified any adverse events including death, cerebrovascular deficit, or other ischemic complications that were not related to unrecognized intraoperative malperfusion syndrome.
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Comment
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The optimal cannulation site for repair of acute ascending aortic dissection is still controversial because of the lack of randomized trials [12]. Our experience with femoral cannulation in this study revealed malperfusion in only 3 of 107 patients. These patients had no neurologic deficit after the operation and recovered well after our surgical modification. Although this was not intended to be a comparative study of different methods of cannulation, this study indicated that the traditional approach of femoral cannulation and management with both radial artery pressure monitorings and evaluation of the size of the true lumen with TEE was safe.
The most popular sites for cannulation in this setting are the femoral artery [13]. Femoral cannulation is relatively easy, with easy vascular repair at the end of the case. A broad spectrum of approaches to these vessels has been published with satisfactory results [12]. Furthermore, femoral cannulation may be ideal in patients with hemodynamic instability who require urgent initiation of cardiopulmonary bypass. However, retrograde embolization, malperfusion of the true lumen, and increasing evidence of the benefits of antegrade perfusion during aortic arch surgery resulted in the search for an alternative site of cannulation [2, 3, 14]. Therefore, antegrade perfusion through an axillary artery has recently come to be preferred over retrograde perfusion through a femoral artery as a means of cardiopulmonary bypass in operations for type A aortic dissection [4–8]. The advantages of providing antegrade arterial flow are based on avoidance of the complications associated with retrograde perfusion, such as organ malperfusion and retrograde embolization with thrombi or atherosclerotic debris. In this study, the contraindications for femoral cannulation were in patients with arteriosclerotic aortic disease that might predispose to retrograde embolization, dissection of the femoral artery, and preoperative symptomatic lower limb ischemia because of the probability of the need for femorofemoral bypass. Despite these preoperative contraindications, 86.3% of the 124 patients had femoral cannulation. Previous studies support our experience that arteriosclerosis among patients with aortic dissection is less common than among patients with aortic aneurysm [15, 16].
Organ malperfusion is caused by dissection of the organ vessels themselves or by compression of the origin of these vessels by the false lumen. Previous studies reported that the incidence of intraoperative malperfusion syndrome with femoral cannulation was 2.5% to 13% [14, 17]. However, malperfusion syndrome also occurs with axillary cannulation. The dissection of the subclavian artery with an intimal tear in the brachiocephalic trunk or subclavian artery can cause retrograde carotid dissection and cerebral malperfusion. Imanaka and colleagues [18] reported fetal intraoperative dissection due to perfusion through the right axillary artery in 1 of 43 patients. Schachner and colleagues [19] reported that conversion from axillary cannulation to femoral artery was necessary in 2 of 22 patients. In 1 patient, the conversion was necessary because of significant resistance in the artery during advancement of the cannula, and in the other patient, because of insufficient cardiopulmonary bypass flow. Strauch and colleagues [20] reported that 5% of patients required alternative cannulation for various reasons or had complications attributable to axillary cannulation.
Recently, Reece and coworkers [21] introduced direct cannulation of the dissected ascending aorta. Their data showed the group with peripheral cannulation experienced more cardiac events and higher 30-day mortality than the group with aortic cannulation, although neurologic complications and hospital mortality were similar between the two groups [21]. Wada and associates [10] reported excellent results using transventricular cannulation for acute dissection. There were no conversions to cannulation of another artery and no malperfusion events. Cardiopulmonary bypass flow was sufficient in all cases. They found that this technique was limited in patients with severe aortic stenosis and previous cardiac surgery, and there was occasional bleeding at the access site.
These data suggest that central cannulation may decrease the incidence of malperfusion syndrome during cardiopulmonary bypass compared with peripheral arterial cannulation. In theory, the institution of antegrade flow into the true lumen may reduce the probability of distal malperfusion because of restoration of flow to the true lumen. However, despite these favorable findings, these data are not meant to advocate central cannulation over peripheral cannulation. During the study period, transventricular cannulation was used as the first choice of cannulation site in 10 patients based on modification of our strategy, and was used as the second choice in 14 who was contraindication of femoral cannulation. Our experience in these 24 cases was that bleeding problems occurred in 2, conversion was necessary because of severe aortic regurgitation in 1, and malperfusion of the right brachiocephalic artery in 2. Because these patients were the first 10 patients and it might have been an initial technical problem, we currently use transventricular cannulation as a second choice. We agree with the opinion of Reece and associates [21] that the site of cannulation should be tailored to each specific patient on the basis of patient characteristics and dissection anatomy.
In this study, we monitored the radial arterial pressure bilaterally and used TEE to monitor the dissected aorta. The main cause of the malperfusion complicated by retrograde perfusion was compression of the true lumen by the false lumen in the descending aorta or abdominal aorta. Therefore, attention was provided to the area of the true lumen, especially in the proximal descending aorta. Fusco and associates [17] reported malperfusion on the initiation of cardiopulmonary bypass in 3 of 86 patients. Malperfusion on clamping the aorta or on resumption of aortic flow was not observed in any patient. These data support our results that malperfusion only occurred at the initiation of cardiopulmonary bypass. After recognizing malperfusion, the cannula had to be repositioned to another suitable site in each individual case. In this study, the 3 patients that had malperfusion after femoral cannulation were switched to transventricular cannulation at a body temperature of approximately 36°C. With this procedure, approximately 1 minute was required to start perfusion again. To prevent malperfusion regardless of the cannulation site, there is a need for continuous intraoperative monitoring of organ blood flow. This unfortunate eventuality suggests that bilateral cerebral blood supply should be monitored continuously. Recently, we have started to monitor cerebral oxygen saturation (rSO2) during all operations for aortic dissection.
A limitation of this observational study is that it could have significant bias, especially in patient selection. We used transventricular cannulation or ascending aortic cannulation as the primary site in 15 patients. Seventeen (13.7%) of the remaining 124 patients had a contraindication for femoral cannulation, as mentioned above. The rate of contraindication for femoral cannulation was similar to the previous report [4]. Of the 32 patients with an alternative cannulation site, there were 3 in-hospital deaths (9.4%). Two were caused by cerebral infarction and 1 was caused by mediastinitis. Cerebrovascular deficit occurred in 4 patients (12.5%), including in-hospital deaths. Another limitation is number of patients. The total number of patients enrolled was small, but this is the largest number of cases published to date with this level of intraoperative monitoring. The small sample size also prevented identification of independent predictors of intraoperative malperfusion syndrome. Our preliminary results need to be confirmed by studies in a larger group of patients.
In conclusion, although this study does not advocate using the femoral approach in all cases of ascending aortic dissection, malperfusion syndrome related to femoral artery cannulation has an acceptable incidence (2.8% in all patients, 4.1% in classical dissection patients), and can be managed with both radial artery pressure monitoring and evaluation of the size of the true lumen with TEE, particularly at the initiation of cardiopulmonary bypass. This study suggests femoral artery cannulation can be used safely for establishing cardiopulmonary bypass under appropriate intraoperative monitoring.
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Acknowledgments
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The authors thank Dr H. Watanabe and Dr M. Aikawa for echocardiographic contribution and Dr T. Tobaru for medical management of this study.
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References
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Abstract
Introduction
