Ann Thorac Surg 2002;74:606-608
© 2002 The Society of Thoracic Surgeons
How to do it
Simplified technique for retrograde cerebral perfusion during repair of distal aortic arch and proximal descending thoracic aorta
Shiv Kumar Choudhary, MCh*a,
Raja Joshi, MCha,
Anil Bhan, MCha,
Panangipalli Venugopal, MCha
a Cardiothoracic Center, All India Institute of Medical Sciences, New Delhi, India
Accepted for publication January 4, 2002.
* Address reprint requests to Dr Choudhary, Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi-110029, India
e-mail: shivchoudhary{at}hotmail.com
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Abstract
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Lesions of distal aortic arch and proximal descending thoracic aorta require a posterolateral thoracotomy approach and total circulatory arrest. Retrograde cerebral perfusion through the superior vena cava is technically difficult in such situations. We describe a simplified technique for delivery of retrograde cerebral perfusion through the left internal jugular vein.
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Introduction
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Surgical correction of the distal aortic arch and, very often, proximal descending thoracic aorta is performed using deep hypothermic circulatory arrest. Mostly, lesions of the distal aortic arch and proximal descending thoracic aorta are approached through a left posterolateral thoracotomy, and hence, delivery of retrograde cerebral perfusion (RCP) through the superior vena cava becomes technically difficult. It becomes even more difficult if there are intrapericardial adhesions because of previous cardiac procedures. Furthermore, the traditional circuit used for RCP is a complex one. We describe a simplified technique to deliver RCP through the left internal jugular vein (LIJV) using a modified circuit.
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Technique
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A 30-year-old woman, who had previously undergone aortic root replacement for type A dissection 1 year previously, presented with massive hemoptysis. Magnetic resonance scan showed massive aneurysm of the distal aortic arch and proximal descending thoracic aorta. The left subclavian artery was also involved in the aneurysmal process. The patient was admitted for emergency operation.
The patient was placed in the right lateral decubitus position with the left pelvis rotated posteriorly for access to the left femoral vessels. The left side of the neck was also included in drapes. During cleaning, one attendant held the left upper limb that was cleaned, painted, and draped, as in surgical preparation for radial artery harvest, and it was kept folded across the abdomen (Fig 1).
A 5-cm-long incision was made along the anterior border of sternocleidomastoid muscle, and the LIJV was dissected and looped. Once the LIJV was dissected and looped, the left upper limb was abducted, externally rotated, and handed over to the anesthetist, to be rested on the frame (Fig 2).
The aorta was approached by means of a posterolateral thoracotomy through the fourth intercostal space.
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Fig 1. Position of patient and left upper limb during dissection of left internal jugular vein. The left upper limb was draped and was kept folded across the abdomen.
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Fig 2. Once the left internal jugular vein was dissected, the left upper limb was shifted toward the head. The final position of the patient, the cardiopulmonary bypass circuit, and the retrograde cerebral perfusion (RCP) circuit are shown.
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Cardiopulmonary bypass was established with left femoral vessel cannulation. The arterial line was bifurcated to perfuse the proximal aorta during distal reconstruction and thus to reduce the duration of circulatory arrest. An additional angled venous cannula was placed in the pulmonary artery.
To deliver RCP, a retrograde cardioplegia cannula was inserted into the LIJV and was connected to the cardioplegia delivery system (Fig 3).
The sidearm of the cardioplegia cannula was connected to the pressure transducer.
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Fig 3. Modified extracorporeal circuit to deliver retrograde cerebral perfusion (RCP). (BCD = blood cardioplegia delivery system.)
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Total circulatory arrest was achieved at 18°C and the aorta was opened. Retrograde cerebral perfusion was started with a flow of 500 to 600 mL/min with a pressure limit of 25 mm Hg. The distal aortic arch was transected between the left common carotid artery and the left subclavian artery. A 22-mm polyethylene terephthalate fiber (Dacron) graft was anastomosed to the aortic arch using continuous 3-0 polypropylene suture. An arterial cannula was inserted into the graft and was connected to the other limb of the arterial line. Arterial flow was restarted, and the graft was clamped distally. Rewarming was started. The left subclavian artery was anastomosed to the aortic graft using a 10-mm interposition graft. The distal end of the aortic graft was anastomosed to the distal descending thoracic aorta, and full flow was reestablished.
The circulatory arrest period was 32 minutes. The whole procedure could be accomplished without any difficulty. The patient made an uneventful recovery without any neurologic deficit and was extubated after 24 hours.
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Comment
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Subsequently we have used this technique in 5 more patients. Two patients had distal aortic arch aneurysms, and 3 patients had thoracoabdominal aneurysms and required total circulatory arrest for proximal anastomosis. Circulatory arrest period ranged from 24 to 56 minutes. All the patients regained consciousness in 12 to 18 hours and could be extubated after 22 to 48 hours. None of the patients had any neurologic deficit and could be discharged from the hospital after 7 to 13 days.
Delivery of RCP through the LIJV has distinct advantages over the superior vena caval route, especially during reoperation. The circuit remains away from the surgical field and does not interfere with the surgical procedure. Although Deeb and colleagues [1] have used the LIJV for RCP, they first dissect out and loop the LIJV in the supine posture, and close the neck wound. Then the patient is turned for the posterolateral thoracotomy and is redraped. The neck wound is subsequently opened to retrieve the LIJV. This whole sequence makes the procedure cumbersome and time-consuming.
In place of the traditional circuit, we have used a retrograde cardioplegia cannula and cardioplegia delivery system for RCP. The retrograde cardioplegia cannula can be inserted with greater ease, and its sidearm also provides opportunity for venous pressure monitoring. With the use of a cardioplegia delivery system, the perfusate temperature can be controlled in a better way, and the perfusate temperature could be lowered down to 10°C without cooling the entire blood volume. Using this circuit, it is possible to continue RCP along with arterial inflow at the termination of circulatory arrest. This helps in complete removal of air from the aortic arch and the arch vessels.
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References
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- Deeb G.M., Jenkins E., Bolling S.F., et al. Retrograde cerebral perfusion during hypothermic circulatory arrest reduces neurologic morbidity. J Thorac Cardiovasc Surg 1995;109:259-268.[Abstract/Free Full Text]
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Abstract
Introduction
