Ann Thorac Surg 2008;85:1624. doi:10.1016/j.athoracsur.2008.02.092
© 2008 The Society of Thoracic Surgeons
Original Articles: Adult Cardiac
Invited Commentary
Ikuo Fukuda, MD
Department of Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori 036-8562, Japan
(Email: ikuofuku{at}cc.hirosaki-u.ac.jp).
Shimokawa and colleagues [1] are to be congratulated on their excellent outcomes using standard femoral arterial access for type A acute aortic dissection (AAD). The optimal arterial perfusion site for AAD is controversial. Recently, the use of axillary perfusion has been popular, but this report makes us reconsider the advantage of femoral arterial cannulation. Organ malperfusion may occur due to the dissection. In the past, the incidences of symptomatic cerebral ischemia, visceral organ ischemia, and iliofemoral ischemia in aortic dissection were 9.3, 8.3, and 11.7%, respectively [2]. Retrograde perfusion from the femoral artery may perfuse the false lumen, which may compress the true lumen. The possibility can not be foreseen until cardiopulmonary bypass is initiated. The problem may also cause obstruction of the true lumen in the ilio-abdominal region and high resistance in the perfusion circuit as shown in case 3 [1]. The authors monitored bilateral radial arterial pressure at the initiation of cardiopulmonary bypass and the size of the true lumen was evaluated with transesophageal echocardiography. Surgical outcomes were outstanding, with 0.9% mortality and 6.5% stroke morbidity, despite the fact that 19.6% of patients had preoperative shock. Nevertheless, readers should carefully interpret these results because of selection bias for femoral artery cannulation. Approximately 21% of patients (32 of 139) were excluded from this study because an alternative site was used for cannulation. Six patients who had preoperative malperfusion, femoral artery dissection, or either lower or upper limb ischemia, were excluded. Also, 33 patients (30.8%) who had intramural hematoma were included. Intramural hematoma reduces the risk for malperfusion induced by extracorporeal circulation.
The advantage of femoral artery perfusion is simplicity and popularity. Exposure of the femoral artery is easy and quick. Femoral artery perfusion can be performed before opening the pericardium if the risk of rupture is high. This study teaches us that femoral artery perfusion is still useful as arterial access in AAD, if appropriate patients are selected and have operation with careful monitoring. However, the arterial perfusion site may need to be changed if malperfusion syndrome occurs. Alternative perfusion sites, including transventricular cannulation, direct aortic cannulation, and axillary artery cannulation, should be selected based on the anatomy of the dissection. In the end, the surgeon's experience determines the cannulation site.
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References
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- Shimokawa T, Takanashi S, Ozawa N, Ito T. Management of intraoperative malperfusion syndrome using femoral artery cannulation for repair of acute type A aortic dissection Ann Thorac Surg 2008;85:1619-1624.[Abstract/Free Full Text]
- Borst HG, Heinemann MK, Stone CD. Surgical treatment of aortic dissectionNew York: Churchill Livingstone; 1996. pp. 250-271.
Related Article
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Management of Intraoperative Malperfusion Syndrome Using Femoral Artery Cannulation for Repair of Acute Type A Aortic Dissection
- Tomoki Shimokawa, Shuichiro Takanashi, Naomi Ozawa, and Tsuyoshi Itoh
Ann. Thorac. Surg. 2008 85: 1619-1624.
[Abstract]
[Full Text]
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