| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, New York
Accepted for publication July 9, 2008.
* Address correspondence to Dr Di Luozzo, Mount Sinai Medical Center, Department of Cardiothoracic Surgery, 1190 Fifth Ave, Box 1028, New York, NY 10029 (Email: gabriele.diluozzo{at}mountsinai.org).
 |
Abstract |
|---|
 Top Abstract IntroductionCase ReportsCommentReferences |
|---|
|
Introduction |
|---|
|
TopAbstractIntroductionCase ReportsCommentReferences |
|---|
At our institution, most elective and emergency DTA/TAAA operations are connected to the CPB circuit by the femoral artery and vein. We rarely use left atrial-femoral bypass because venoarterial bypass without a reservoir, in addition to providing distal perfusion, reduces right heart strain and improves oxygenation in patients with pulmonary disease on single-lung ventilation. Venoarterial bypass reduces the risk of air embolism, allows for incorporation of a heat exchanger and a reservoir, if needed, and conversion to full CPB and DHCA.
Most publications focus on arterial access to optimize neuroprotective techniques and reduce atheroembolism. As for most institutions, the left atrium or femoral vein for partial or full CPB is advantageous for the resection of TAAAs or DTAs. On rare occasions, optimal femoral venous access for establishing CPB is not possible.
Venous access can be challenging through a left thoracotomy; however, the pulmonary artery and vein and right atrium can be approached from this incision. We present our experience in 6 patients with DTA/TAAAs in which the supradiaphragmatic inferior vena cava (IVC) was cannulated when the femoral vein was inaccessible.
|
Case Reports |
|---|
|
TopAbstractIntroductionCase ReportsCommentReferences |
|---|
|
Patient 2
A 66-year-old man with history of coronary artery disease required coronary artery bypass grafting (CABG) and had a ruptured AAA. A thoracic atherosclerotic aneurysm was successfully treated with an endovascular stent; however, the visceral segment of the aorta significantly expanded in a 1-year interval.
Patient 3
A 78-year-old man with coronary artery disease, cerebrovascular disease, hypertension, and myocardial infarction required CABG. He had an infrarenal aortic aneurysm, which was treated with an endovascular stent; however, multiple interventions were required for endoleaks and further cephalad expansion of the abdominal aneurysm. The visceral segment of the abdominal aorta dilated to a maximum diameter of 8.1 cm.
Patient 4
A 74-year-old woman with hypertension was monitored with serial imaging studies for a known TAAA. After 6 years of surveillance, the lower portion of the TAAA increased in size to a maximum diameter of 6.2 cm. For 2 weeks before operation the patient, had severe, intermittent back pain.
Patient 5
An 80-year-old man with asymptomatic coronary artery disease and hyperlipidemia was discovered on physical examination to have a large pulsatile mass in the abdomen. A CT scan showed an 8.0-cm type III TAAA and stenosis of the left renal artery.
Patient 6
A 56-year-old woman who presented with pelvic pain was found on abdominal ultrasound to have a large abdominal aneurysm. The CT scan showed a 5-cm aortic arch aneurysm and a 7-cm type III TAAA.
Operative Technique
All patients are approached through a left thoracoabdominal incision with circumferential division of the diaphragm. The retroperitoneal space is entered, and the peritoneal contents are mobilized to expose the thoracoabdominal aorta. A vertical incision is made in the left groin to access the femoral artery and vein. The diseased aorta is mobilized and intercostal and lumbar arteries are ligated under somatosensory and motor-evoked potential monitoring. Once the aortic mobilization is completed, the patient is administered heparin.
The Selinger technique is used to introduce an 18-gauge catheter into the femoral vein, followed by the placement of the guidewire. The cardiac anesthesiologist visualizes the right atrium on transesophageal echocardiogram and focuses on the appearance of the guidewire. In all of the 6 patients, the guidewire was unable to thread past 20 cm and enter the IVC. Multiple unsuccessful attempts were made to attain venous access through the femoral vein. No attempt was made to cannulate directly the intraabdominal IVC.
The diaphragm is dissected away from the pericardium and followed posteriorly towards the IVC. The tissue surrounding the IVC is not dissected extensively. Attention to the phrenic nerve is always prudent; however, the nerve is medial and anterior to the IVC dissection. A 4-0 Prolene purse string suture (Ethicon, Somerville, NJ) is placed on the lateral surface of the IVC. Depending on the size of the patient and the IVC, a single-stage venous cannula is placed into the supradiaphragmatic IVC and directed towards the right atrium (Fig 1). The transesophageal echocardiogram confirms placement of the venous cannula in the right atrium and adequate drainage of the heart.
|
|
Comment |
|---|
|
TopAbstractIntroductionCase ReportsCommentReferences |
|---|
We present 6 patients in which the femoral vein or distal IVC was inaccessible because of a possible obstruction or unrecognized anomaly. Neri et al [4, 5] have described their experience with access to the IVC either suprahepatically or trans-pericardially. We concur with their observation that this approach can be easily performed with caution, especially, in patients with previous cardiac operations and adhesions. In all 6 patients, the venous access using a percutaneous wire technique from the femoral vein was not successful. This alternative approach provides adequate venous drainage to successfully maintain a flaccid heart, adequate perfusion pressure, and arterial flow and support for DHCA. The cannulas that we have been able to safely place into the IVC provide adequate venous return for to achieve partial or full CPB (Table 1).
In this small sample of patients requiring an alternative location for venous access, the intended resection was successfully completed. A large abdominal component of the TAAA appears to be a common preoperative variable to all the patients requiring the supradiaphragmatic venous cannulation. The AAA may impinge or distort the IVC or the iliac vein–IVC junction, resulting in an acute angulation not conducive for guidewire placement. In addition, there was no history of deep vein thrombosis or placement of an IVC filter in any of the patients. Venous obstruction from retroperitoneal fibrosis is a possible explanation; however, none of these patients had a history of radiation, an inflammatory abdominal aneurysm, malignancy, or clinical evidence of lower body venous hypertension.
In brief, our preferred approach is venoarterial bypass for resection of TAAAs. The cannulation of the supradiaphragmatic IVC can be performed safely with optimal exposure of the area. The supradiaphragmatic IVC can be approached in patients with a history of cardiac operations because the pericardium is not entered during this approach. In all our patients the pericardium was intact, therefore facilitating the identification of the tissue planes and proceeding with the dissection. In addition, it is an excellent option in patients with a vena caval filter. Supradiaphragmatic IVC cannulation should be added to the armamentarium of cardiac surgeons for the infrequent, difficult femoral vein access in aneurysm operations.
|
References |
|---|
|
TopAbstractIntroductionCase ReportsCommentReferences |
|---|
This article has been cited by other articles:
|
|
 |
|
  E. Civilini, G. Melissano, and R. Chiesa Improved Cannulation: Technique for Thoracoabdominal Aortic Aneurysm Repair Ann. Thorac. Surg., February 1, 2010; 89(2): 675 - 675. [Full Text] [PDF]
|
|
|
|
|
|
G. Di Luozzo Reply. Ann. Thorac. Surg., February 1, 2010; 89(2): 675 - 675. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 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 |
