Ann Thorac Surg 2008;86:671-672. doi:10.1016/j.athoracsur.2008.01.011
© 2008 The Society of Thoracic Surgeons
How To Do It
A Counterpulsation Technique for Use During Complicated Aortic Surgery With Residual Thoracoabdominal Aortic Aneurysm
Yoshikatsu Saiki, MD, PhD*,
Ichiro Yoshioka, MD, PhD,
Koichi Tabayashi, MD, PhD
Department of Cardiovascular Surgery, Graduate School of Medicine, Tohoku University, Sendai, Japan
Accepted for publication January 3, 2008.
* Address correspondence to Dr Saiki, Department of Cardiovascular Surgery, Tohoku University, Graduate School of Medicine, Seiryomachi, Aoba-ku, Sendai, 980-8574, Japan (Email: ysaiki{at}mail.tains.tohoku.ac.jp).
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Abstract
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Mechanical circulatory support can be difficult for patients with thoracoabdominal aortic disease. We herein describe a counterpulsation technique using an intra-graft balloon pump that can be safely used in the setting of thoracoabdominal aortic aneurysm remaining immediately after aortic root and arch replacement coupled with coronary artery bypass grafting.
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Introduction
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Intra-aortic balloon pumps are the most frequently used circulatory assist devices for patients with severely depressed cardiac function after cardiac surgery. However, this approach is generally contraindicated when the patient has thoracoabdominal aortic disease, such as aortic dissection and aneurysm, or both. We herein describe a counterpulsation technique that can be safely used in the setting of thoracoabdominal aortic aneurysm remaining immediately after aortic root and arch replacement coupled with coronary artery bypass grafting.
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Technique
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A 49-year-old man was referred to our hospital for surgical management of thoracoabdominal aortic aneurysm. Preoperative examinations revealed aortic regurgitation and stenosis of the left main coronary artery, along with dilation of the ascending aorta, aortic arch, and thoracoabdominal aorta. A two-stage approach was indicated for treatment of the extensive disease of the thoracic aorta. The patient underwent technically uneventful aortic root replacement using a composite graft with a mechanical valve, total aortic arch replacement using the elephant trunk technique, and coronary artery bypass grafting using a saphenous vein graft for the left circumflex artery, and a radial artery graft for the left anterior descending artery. Intraoperatively, the surgery was complicated by depressed myocardial function due to intractable vasospasm of the radial artery, so we added a saphenous vein graft to the left anterior descending branch to restore sufficient coronary arterial flow. Off-pump coronary artery bypass grafting was not the option of choice because the myocardium was markedly edematous and the heart distended by that time; therefore, a second pump run and cardioplegic cardiac arrest were unavoidable. After completion of the additional coronary bypass grafting, we were not able to wean the patient off the cardiopulmonary bypass despite appropriate medical support. Under these circumstances, we therefore decided to use an intra-graft balloon pump (IGBP).
Partial clamping of the ascending aortic graft was not feasible because there were three proximal anastomoses for the coronary bypass grafts. More to the point, we were concerned that in creating the proximal orifice for the IGBP in the ascending aortic graft there would be a certain risk of potential thromboemboli forming around the balloon and moving into the coronary or cerebral circulation. The aortic arch distal to the replaced brachiocephalic artery was selected as an alternative location for the proximal orifice for the IGBP. Two Pean clamps were applied to the replaced transverse aortic arch in a "V" configuration, and no additional systemic heparin was administered. A longitudinal incision was made on the graft between the two clamps. Then a 22-mm prosthetic vascular graft was anastomosed to the arch graft in an end-to-side fashion using a running 4-0 polypropylene suture (Fig 1). A vascular clamp was subsequently applied to the newly constructed side graft, and the two side-biting Pean clamps were removed. Air evacuation and hemostasis were confirmed. The left parietal pleura were dissected down from the anterior chest wall to create sufficient space for routing the IGBP without causing any damage to the left lung (Fig 1). A 35-mL balloon pump was inserted from the left subcostal area through the skin and rectus abdominis muscle into the left extrapleural space. The side graft was then cut to a length that was just sufficient to house the balloon pump. The pump shaft was inserted into the graft, and the distal end of the graft was tied around the balloon shaft using silk ties. Care was taken to keep the tip of the balloon sitting inside the graft intended to house the IGBP. Counterpulsation was then initiated, which resulted in instantaneous systolic unloading and diastolic augmentation, as confirmed by monitoring the arterial pressure waveform (Fig 2). An intraoperative transesophageal echocardiogram showed that coronary bypass graft flow had increased markedly, and myocardial contractility had also improved. The patient was subsequently weaned off the cardiopulmonary bypass. The side graft was displaced into the left extrapleural space away from the midline. Primary sternal closure would have been technically feasible without causing the side graft to compress the heart; however, the sternum was left open in this case, and the skin was covered with an Esmarch bandage (Currie Medical Technology Inc, Monrovia, CA) and an antimicrobial incise drape to avoid placing any additional stress on the edematous heart. The patient remained hemodynamically stable thereafter, and on postoperative day 4 he underwent uneventful sternal closure.
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Fig 1. The intra-graft balloon pump (IGBP) system: (A) intraoperative photograph and (B) schematic drawing. (AG = arch graft; BCA = brachiocephalic artery graft; CR = chest retractor; R = retractor; SVCC = superior vena cava cannula; SVG = saphenous vein graft.)
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Fig 2. Electrocardiogram (upper) and arterial pressure waveform (lower) showing that the intra-graft balloon pump produced significant diastolic augmentation of systemic pressure.
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Comment
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Miller and colleagues [1] first applied balloon counterpulsation within a prosthetic graft anastomosed to the pulmonary artery to treat acute right heart failure. Thereafter, Matsuda and colleagues [2] experimentally evaluated use of the IGBP in the descending thoracic aortic position in the context of left heart failure and concluded that balloon pumps can play a supportive role for the native descending thoracic aorta when placed within prosthetic grafts. Hoka and colleagues [3] described a modified version of intra-graft balloon pumping used in the ascending aortic position. Although distal thromboembolic events associated with intra-aortic balloon pump (IABP) are generally uncommon, there is a potential risk of cerebral or coronary artery thromboembolism with antegrade IABP cannulation in the ascending aorta [4]. Emboli in the setting of IGBP are most likely to originate from either small thrombi forming on the balloon itself or thrombi forming within the prosthetic graft that houses the balloon, particularly at the blind end. For these reasons, we attempted to locate the IGBP orifice as distally as possible within the operative field. Another matter for concern is that when concomitant coronary artery bypass grafting is performed, as in the present patient, the ascending aortic graft may not provide sufficient space for IGBP connection. In such a situation, the arch graft can be an alternative target for installation. Storing the IGBP within the chest cavity is another technical challenge, but creating extrapleural space anteriorly allows the IGBP to be routed without compressing the heart or impairing left lung function. After our first success in the original patient, we successfully applied the same approach to 3 other patients who had dissecting thoracoabdominal aortic aneurysm remaining after undergoing total aortic arch replacement. We believe that our IGBP technique is a useful adjunct in the treatment of depressed myocardial function in the setting of residual thoracoabdominal aortic aneurysm immediately after aortic root and arch replacement.
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References
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- Miller DC, Moreno-Cabral RJ, Stinson EB, Shinn JA, Shumway NE. Pulmonary artery balloon counterpulsation for acute right ventricular failure J Thorac Cardiovasc Surg 1980;80:760-763.[Abstract]
- Matsuda H, Ootake S, Taka Y, et al. Experimental study on intra-Gore-Tex graft balloon counterpulsation Shinzo 1981;13:1434-1435.
- Hoka S, Tashiro T, Haruta Y, et al. Modified application of intra-aortic balloon pump after repair of thoracic dissection aneurysm J Cardiovasc Surg 1992;33:41-43.[Medline]
- Meldrum-Hanna WG, Deal CW, Ross DE. Complications of ascending aortic intraaortic balloon pump cannulation Ann Thorac Surg 1985;40:241-244.[Abstract/Free Full Text]
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Abstract
Introduction
