Ann Thorac Surg 2009;88:262-263. doi:10.1016/j.athoracsur.2008.11.064
© 2009 The Society of Thoracic Surgeons
Case Reports
Iliac Arterial Intussusception From an Aortic Endoclamp Catheter
Kaan Inan, MD,
Alper Ucak, MD,
Ahmet U. Gullu, MD*,
Ahmet T. Y
lmaz, MD
Department of Cardiovascular Surgery, Gulhane Military Academy of Medicine, Haydarpasa-Istanbul, Turkey
Accepted for publication November 24, 2008.
* Address correspondence to Dr Gullu, Mutevelli Cesme Cad, Murat Sitesi S Blok, Istanbul, 34662, Turkey (Email: aumitgullu{at}yahoo.com).
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Abstract
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Minimally invasive cardiac surgical procedures are gaining widespread acceptance with the advent and development of the femoral route for cardiopulmonary bypass. Aortic endoclamps are widely used and are one of the most important parts of these surgical techniques. This report presents iliac arterial intussusception from an aortic endoclamp catheter, which is a very rare complication with this type of device. Preventative strategies are presented.
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Introduction
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Minimally invasive cardiac surgery is still a challenge, even with the advent of new and improved surgical equipment. Cardiac surgery through a minithoracotomy and video-endoscopy (robotic, video thoracoscopic) is still evolving. Femorofemoral perfusion techniques are necessary for minimally invasive cardiac operations, and aortic endoclamping and femoral venous cannulation are the most important parts of these surgical techniques [1].
As with all innovations in new surgical equipment, however, this is not problem-free. The most common complications of the operation performed by peripheral cardiopulmonary bypass systems are embolism, dissection, balloon migration, kinking of the cannula, cerebral ischemia, and local wound problems in the groin [2, 3]. In this report, we present iliac arterial intussusception from an aortic endoclamp catheter, which is a very rare complication of this type of device, and also recommend preventative strategies.
A 20-year-old man underwent repair of an ostium secundum type atrial septal defect in our clinic. The operation was planned with anterior minithoracotomy, femoral aortic endoclamp (Remote Access Perfusion Cannula; Estech, San Ramon, CA) cannulation, and femoral venous and selective vena cava superior cannulation under transesophageal echocardiography (TEE) guidance. The aortic endoclamp balloon was checked and inflated according to the instructions.
The operation was uneventful until the release of aortic clamping: when the balloon deflated, the syringe was filled with blood. We introduced the guidewire to pull back the endoclamp, but it was trapped under the inguinal ligament and could not be retrieved. We then made a small incision for retroperitoneal iliac exploration.
The distal silicone 10-cm part of the cannula was folded and trapped just above the iliac bifurcation (Figs 1 and 2).
After vascular clamping, we made a longitudinal arteriotomy and retrieved the distal part of the endoclamp. We saw a 4- to 5-cm dissected segment during the iliac exploration and interposed a 10-mm graft made of Dacron (DuPont, Wilmington, DE) between the proximal common iliac artery and common femoral artery. The rest of the operation was completed as usual. The patient's postoperative follow-up was uneventful, and he was discharged on postoperative day 7.
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Comment
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Minimally invasive cardiac surgical procedures are gaining widespread acceptance with the advent and development of the femoral route for CPB. The perfusion cannula that we use during minimally invasive cardiac procedures provides both aortic perfusion and cardioplegia delivery through femoral artery for CPB, with required blood flow rates of 1 to 5 L. This cannula is an 81-cm-long flexible tube with 3 lumens and an inflatable balloon at the distal end that provides aortic occlusion instead of aortic cross-clamping. The device has a central lumen for the delivery of arterial blood through multiple distal outlets, a lumen for both the delivery of cardioplegia and left ventricular venting at the aortic root, and finally, a small lumen for control of the distal balloon.
The obturator provides stiffness for the cannula, and attempted insertion of the cannula without the use of the obturator may cause a malposition. It should be completely inserted into the cannula before the cannula is advanced over the guidewire. For positioning and monitoring of cannula and the balloon, the device should be placed under the guidance of the TEE. Fluoroscopic monitoring may be used if desired [1–4].
We operated on 25 patients with these methods. Of these, 17 were atrial septal defect closure, 5 were ventricular septal defect closure, and 3 were mitral valve repair/replacement. No perioperative complications occurred, and the patients had an uneventful postoperative course.
The most common complications of the operation performed by peripheral CPB systems are embolism, dissection, balloon migration, kinking of the cannula, cerebral ischemia and local wound problems in the groin. We have not seen any of these complications in our series, however [2, 3]. The complication in our last atrial septal defect patient was very unusual.
The possible cause of the folding was probably due to the rupture of the clamping balloon, which was inflated according to the manufacturer's instructions for the device, and the filling of the balloon with antegrade aortic flow blood. We strongly recommend a thorough check of the balloon before insertion and advise that great care be taken when the balloon is deflated. Any concern about the retrieval should be evaluated under TEE guidance. Avoidance of excessive force to the cannula during retrieval is essential. In addition, guidewire insertion should be considered as the initial interventional step for reinforcing the cannula. In some cases, obturator insertion could be the second option.
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References
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- Galloway AC, Shemin RJ, Glower DD, et al. First report of the port access international registry Ann Thorac Surg 1999;67:51-58.[Abstract/Free Full Text]
- Wimmer-Greinecker, Matheis G, Dogan S, et al. Complications of port access cardiac surgery J Cardiac Surg 1999;14:240-245.[Medline]
- Sagbas E, Caynak B, Duran C, et al. Mid-term results of peripheric cannulation after port-access surgery Interact CardioVasc Thorac Surg 2007;6:744-747.[Abstract/Free Full Text]
- Casselman FP, Van Slycke S, Wellens F, et al. Mitral valve surgery can now routinely be performed endoscopically Circulation 2003;108:48-54.[Abstract/Free Full Text]
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Abstract
Introduction
