Ann Thorac Surg 2008;86:669-670. doi:10.1016/j.athoracsur.2008.02.096
© 2008 The Society of Thoracic Surgeons
How To Do It
Modified Cabrol Shunt After Complex Aortic Surgery
Tomas A. Salerno, MD*,
Enisa M.F. Carvalho, BS,
Anthony L. Panos, MD,
Marco Ricci, MD
Division of Cardiothoracic Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida
Accepted for publication February 29, 2008.
* Address correspondence to Dr Salerno, Jackson Memorial Hospital, University of Miami Miller School of Medicine, 1611 NW 12th St, Miami, FL 33136 (Email: tsalerno{at}miami.edu).
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Abstract
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Uncontrollable hemorrhage during complex aortic surgery was controlled by a new modification of the Cabrol shunt, which is reported here.
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Introduction
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Bleeding after complex aortic reconstructive procedures may be impossible to control in certain situations [1]. Perigraft-to-right atrial connection for hemorrhage control during aortic surgery was first described by Cabrol and colleagues [1] in 1978. Since then, modifications of this technique have been reported by Hoover and colleagues [2] in 1987, and by our group in 1989 [3]. Here we report another modification of the Cabrol shunt.
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Technique
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Catastrophic hemorrhage was encountered during aortic surgery in a 69-year-old woman undergoing redo aortic valve replacement, requiring replacement of the ascending aorta with a Hemashield graft (Boston Scientific Corp, Natick, MA). The operation was lengthy; because of friability of tissues, Teflon strips were used to reinforce both the proximal and distal aortic sutures lines using 4-0 polypropylene sutures. Bioglue (CryoLife Inc, Kennesaw, GA) was applied to secure hemostasis upon completion of the anastomoses. Due to long cardiopulmonary bypass time, hypothermia, and circulatory arrest, significant coagulopathy developed after administration of protamine and blood products. On-going bleeding from many operative sites occurred, including bleeding from the aortic suture lines and surrounding tissues. Bleeding continued despite usage of conventional maneuvers, including application of sutures, topical hemostatic agents, and recombinant factor VII. As a result, a bovine pericardial patch, measuring approximately 10 x 8 cm was appropriately tailored to isolate the area of bleeding from the reconstructed ascending aorta as shown in Figure 1. Suturing the patch proceeded from the superior vena cava laterally on the patient's right side along the right atrium inferiorly, and the border of the heart and pulmonary artery on the patient's left side. Due to technical difficulties in dissecting a rather thin and frail right atrium, it was decided to connect the cavity covered by the bovine pericardial patch to the innominate vein using a number 6-mm Hemashield graft (Boston Scientific Corp). The anastomosis between the graft and the innominate vein was constructed using 6-0 polypropylene sutures. Bleeding was controlled, as blood from the aortic suture line and adjacent tissues was redirected to the innoninate vein (Fig 1) creating autotransfusion of shed blood, as described originally by Cabrol and colleagues [1].
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Fig 1. Illustration showing the patch of bovine pericardium sutured to the peri-aortic tissues. The patch is sutured to the superior vena cava on the patient's right side, the right atrium and border of the heart (caudal aspect), the main pulmonary artery on the patient's left side, and the distal ascending aorta and proximal aortic arch (cephalad). A 6-mm Hemashield graft (Boston Scientific Corp, Natick, MA) is then used to redirect blood leaking from the aortic repair site, collecting under the patch, to the innominate vein (ie, autotransfusion).
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Comment
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Creating a connection between the periaortic space and the right atrium is an effective surgical maneuver to deal with uncontrollable aortic bleeding, as first described by Cabrol and associates [1] in 1978. In their technique, the right atrial appendage was connected directly to the aneurymal sac. This technique resulted in effective decompression of the peri-graft, intra-aneurysmal space, and in autotransfusion of blood lost from the bleeding aorta into the central venous system. In 1987, Hoover and colleagues [2] reported modification of this technique by using a 6-mm Gore-Tex graft (W.L. Gore & Associates, Flagstaff, AZ) interposed between the aneurysm wall and the free wall of the right atrium, as opposed to a direct connection as originally described by Cabrol and associates [1]. More recently, modifications of the Cabrol shunt with autologous pericardium, bovine pericardium, or a Hemashield patch were reported by others [3–5]. In our patient, a shunt was created between the bovine pericardial patch, used to cover the reconstructed ascending aorta, and the innominate vein (Fig 1). The advantage of this approach is that it can be used in reoperations in which the right atrium has been incompletely dissected, and in situations in which the right atrium is thin and friable, as in our case. Further studies are needed to determine the potential disadvantages of this approach, and to establish whether this shunt will spontaneously close with time, as suggested in other cases after a classic or modified Cabrol shunt.
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References
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- Cabrol C, Pavie A, Gandjbakhch I, et al. Complete replacement of ascending aorta with re-implantation of the coronary arteries: a new surgical approach J Thorac Cardiovasc Surg 1981;81:209-215.
- Hoover EL, Hsu HK, Arisan E, et al. Left-to-right shunts in control of bleeding following surgery for aneurysm of the ascending aorta Chest 1987;91:844-849.[Medline]
- Blum M, Panos A, Lichtenstein SV, Salerno TA. Modified Cabrol shunt for control of hemorrhage in repair of type A dissection of the aorta Ann Thorac Surg 1989;48:709-711.[Abstract]
- Mancini MC, Cush EM. Shunt control of bleeding after homograft replacement of the ascending aorta Ann Thorac Surg 1999;67:1162-1163.[Abstract/Free Full Text]
- Vogt PR, Akinturk H, Bettex DA, Schmidlin D, Lachat ML, Turina MI. Modification of surgical aorta-atrial shunt for inaccessible bleeding in aortic surgery J Thorac Cardiovasc Surg 2001;49:240-242.
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Abstract
Introduction
