Ann Thorac Surg 2002;74:1071-1074
© 2002 The Society of Thoracic Surgeons
Original article: cardiovascular
Perigraft to right atrial shunt by using autologous pericardium for control of bleeding in acute type A dissections
Haken Posacioglu, MDa*,
Anil Ziya Apaydin, MDa,
Tanzer Calkavur, MDa,
Tahir Yagdi, MDa,
Fatih Islamoglu, MDa
a Department of Cardiovascular Surgery, Ege University Medical School Hospital, 
zmir, Turkey
Accepted for publication June 7, 2002.
* Address reprint requests to Dr Posacioglu, Department of Cardiovascular Surgery, Ege University Medical School Hospital, 35100 zmir, Turkey
e-mail: posacioglu{at}yahoo.com
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Abstract
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BACKGROUND: We report our experience with creating a perigraft to right atrial fistula by using autologous pericardium to control the inaccessible bleeding after aortic root repair in patients with acute type A aortic dissection.
METHODS: Between 1994 and 2001, perigraft to right atrial fistula was used in 7 of 109 patients (mean age; 55 years) who underwent emergency operation for acute type A dissections. A chamber around the aortic graft was created by suturing a patch of pericardium to the right ventricular wall inferiorly, to the pulmonary artery medially, to the Teflon felt at the distal aortic anastomosis or innominate vein superiorly, and to the superior vena cava and right atrium laterally. A large stab wound was created on the medial aspect of the right atrium. The perigraft space was then closed expeditiously.
RESULTS: None of these patients required reexploration for bleeding and they were discharged from the hospital without complications. The average blood and fresh frozen plasma requirement was 3.4 ± 0.9 and 2.7 ± 0.7, respectively. All underwent echocardiographic examination before discharge and no perigraft to right atrial shunt was detected.
CONCLUSIONS: If intractable bleeding is encountered after the administration of protamine and thrombotic agents and a discrete bleeding site can not be found, then a perigraft to right atrial fistula using autologous pericardium can be created as a last resort. It provides primary and definite sternal closure and avoids the detrimental effects of a second pump run and continued bleeding.
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Introduction
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Surgical repair of the ascending aortic aneurysms or acute aortic dissections is occasionally complicated by significant suture line bleeding, particularly after complex reconstructions or prolonged cardiopulmonary bypass (CPB) runs. If a discrete bleeding site cannot be found or the direct suture repair of the leak is ineffective, creating of a perigraft to right atrial fistula is a good option [1]. A second pump run for suture line reinforcement could increase the morbidity and mortality.
In patients undergoing complete resection of the aortic aneurysm wall, there will be insufficient native aorta to wrap around the Dacron graft to create the fistula. In these cases a piece of autologous pericardium can be used. In patients undergoing redo operations, bovine pericardium is a good material.
The concept of perigraft to right atrial shunt was first presented by Cabrol in 1978 [1], and modifications of this technique was reported by Hoover in 1987 [2]. Because it is rarely performed, we would like to reemphasize the importance of this technique and share our experience in patients with acute type A dissections.
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Patients and methods
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Perigraft to right atrial shunt was used in 7 of 109 patients who underwent emergency operation for acute type A dissections between 1994 and 2001. All patients but one were male and the mean age was 55 years old (range 38 to 67 years old). All patients underwent replacement of the ascending aorta with an open distal anastomosis by using a period of hypothermic circulatory arrest. Proximal and distal anastomoses were buttressed with a strip of Teflon felt. Aortic root was replaced in 4 patients: 1 with a homograft and 3 with composite graft containing bileaflet mechanical valve by using button-Bentall technique. Aortic valve was resuspended in 3 patients. Concomitant coronary artery bypass grafting was performed in patient who received homograft aortic root. The 30-day mortality was 25% in acute type A dissections. Composite graft replacement by using button-Bentall technique was performed 21 of 109 patients.
The decision to construct a shunt was made when significant bleeding persists about 20 to 30 minutes after the administration of protamine, despite the transfusion of fresh frozen plasma (FFP), fresh whole blood, thrombotic agents, and mechanical packing.
Comparison of the intraoperative data, chest tube drainage and transfusion requirements of patients with shunt and those of nonbleeders were analyzed in Table 1.
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Table 1. Intraoperative Data, Chest Tube Drainage and Transfusion Requirements of Patients With Shunt and Non-Bleeders
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Statistical analyses were performed by SPSS/PC+ computer program (ver 10.0; Chicago, IL). Continuous data were analyzed using Student’s t-test. All results were expressed as the mean ± standard deviation. Values of p less than 0.05 were considered to be statistically significant.
Technique
In aortic operations, we routinely enter the pericardial space by incising the pericardium along the border of the right pleural space and hang it to the left sternal half with stay stitches in order to prepare a patch of pericardium, measuring roughly 2x2 inches when needed for a perigraft to right atrial fistula (Fig 1).
It is important to close the transverse sinus to prevent posterior leakage in first-time operations. For this purpose posterior wall of the left atrium can be sewn to the anterior aspect of the right pulmonary artery by taking shallow bites. For redo operations, it is not necessary to close the transverse sinus, because of the adhesions.
We use 5/0 polypropylene for construction. Inferiorly, suturing starts at the epicardium of the right ventricular wall, continues towards the main pulmonary artery by taking bites from the adventitia. The Teflon felt at the distal suture line constitutes the superior border of the patch (Fig 2).
Medially sutures can be placed to the posterior pericardium and then to the lateral aspect of the superior vena cava towards the base of the right atrial appandage (Fig 3).
Care should be taken to avoid injury to the sinus node.
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Fig 2. Inferiorly, suturing starts at the epicardium of the right ventricle towards the pulmonary adventitia. The Teflon felt at the distal suture line constitutes the superior border of the patch.
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Fig 3. Medially, sutures can be placed to the posterior pericardium and then to the lateral aspect of the superior vena cava towards the base of the right atrial appendage.
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Before completing the suture line, a large stab wound is created on the medial aspect of the right atrium and this hole is enlarged with the tip of a forceps. The perigraft space is then closed expeditiously (Fig 4).
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Fig 4. Before completing the suture line, a large stab wound is created on the medial aspect of the right atrium and this hole is enlarged with the tip of a forceps. The perigraft space is then closed expeditiously.
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One patient with the right coronary ostium dissection required coronary artery bypass grafting. The proximal anastomosis of the vein graft was constructed to the right brachiocephalic artery after creation of the shunt.
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Results
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The intraoperative data, which were not statistically significant between the patients with shunt and the nonbleeders, are presented in Table 1. The average hypothermic circulatory arrest (HCA) time was 29 ± 6 minutes with a range of 24 to 41 minutes. The aortic cross clamp time average 127 ± 39 minutes with a range of 80 to 167 minutes. The average CPB time was 203 ± 48 minutes with a range of 145 to 260 minutes. The recorded average bleeding rate 30 minutes after administration of protamine was 455 ± 56 mL/30 minute. Total chest tube drainage was 602 ± 94 mL. The average blood and fresh frozen plasma requirement was 3.4 ± 0.9 and 2.7 ± 0.7, respectively.
Postoperative measurements of oxygen saturations of blood samples taken from the proximal and distal ports of the Swan-Ganz catheter (Baxter Healthcare, Deerfield, IL) did not reveal any significant step-up. None of these patients required reexploration for bleeding.
All patients underwent echocardiographic examination before discharge and no perigraft to right atrial shunt was detected. They were discharged from the hospital without any major complications. Also, all patients underwent computed tomography scan (CT) to rule out the possibility of pseudoaneurysm formation in first postoperative month and no pseudoaneurysm formation was detected. Postoperative echocardiogram as well as follow-up CT images revealed clots around the ascending aortic graft.
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Comment
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Bleeding after complex ascending aortic, aortic root or transverse arch surgery that is inaccessible or difficult to control may present a major problem. The incidence of postoperative death due to bleeding was reported to range between 5% to 10% [3]. Crawford and associates [4] reported that reoperation for bleeding was a predictor of early mortality in aortic dissections. We believe that the use of biologic glue by injecting it between the wall-layer of aorta has greatly aided the performance blood-tight anastomosis on the aorta, particularly in acute type A dissection. For this reason, we have used GRF adhesive in 39 of 109 patients with acute type A dissections. Despite the use of GRF in 3 of 7 patients reported in this article significant bleeding encountered, which necessitate the use of Cabrol shunt. Biologic glues required dry field to be effective. Therefore, their application after the occurrence of excessive bleeding would be futile.
Creation of a shunt from the periaortic space to right atrium for control of bleeding was first described by Cabrol and associates in 1978 [1]. They directly connected the tip of the right atrial appendage to the aneurysmal sac. In 1987, Hoover and associates reported modifications of the shunt such as 6-mm Gore-Tex graft (W.L. Gore and Associates, Elkton, MD) interposition between the aneurysm wall and the free wall of the right atrium, direct anastomosis between the right atrial appendage and the aneurysm wall, internal shunt from within the aneurysm wall to the right atrium, created with a 6-mm aortic punch, and Gore-Tex graft interposition between the aneurysm wall and the innominate vein [2]. Hoover and associates [2] preferred graft interposition instead of a direct shunt, because the grafts may be more likely to thrombose and if not, they can be embolized with coils. Cabrol and associates [5] reported persistent left to right shunt in 3 of 260 shunt procedures.
In patients with acute dissections where there is an extensive destruction of the aorta or in patients undergoing complete resection of the aortic aneurysm wall, there will be insufficient native aorta to wrap around the Dacron graft to create the fistula. For this reason, a piece of autologous pericardium can be used. In our technique, the amount of right ventricle that could be covered by the flap is limited to the size of the available anterior pericardium. Because the pericardium only covers a small portion of the right ventricle, we think that pericardial tamponade would not be a problem (Fig 5).
In patients undergoing redo operations, bovine pericardium is a good material for shunt construction. Recently, modifications of the Cabrol shunt with autologous pericardium, bovine pericardium or Hemashield (Meadox Medicals Corp, Oakland, NJ) patch were reported [5–7]. Mancini and associates [3] reported perigraft to right atrial shunt by using a patch of Hemashield graft after homograft aortic root replacement. Vogt and associates [6] reported a technique consisting of anterior mediastinal coverage combined with use of autologous pericardium and xeno-pericardium, and decompression to the innominate vein by using 8-mm Gore-Tex graft.
When coronary artery bypass grafting was needed because of the coronary ostium dissection, finishing the superior suture line below the innominate vein provides enough space and easy construction of proximal anastomosis of the coronary bypass graft to the brachiocephalic trunk. According to the report of Vogt and associates [6], the creation of perigraft to right atrial shunt has no influence on the late outcome of patients who underwent complex aortic surgery.
If an intractable bleeding is encountered after the administration of protamine and thrombotic agents, and a discrete bleeding site can not be found, then a perigraft to right atrial fistula by using autologous pericardium can be created as a last resort. It provides primary and definite sternal closure and avoids the detrimental effects of a second pump run and continued bleeding.
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Acknowledgments
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We thank Halil Uç, MD, for his illustrations.
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References
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- Cabrol C., Pavie A., Gandjbakhch I., et al. Complete replacement of the ascending aorta with re-implantation of the coronaryarteries: a new surgical approach. J Thorac Cardiovasc Surg 1981;81:209-215.
- Hoover E.L., Hsu H.K., 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.[Abstract/Free Full Text]
- Kouchoukos N.T., Wareing T.H. Management of complications of aortic surgery. In: Waldhausen J.A., Orringer M.B., eds. Complications in cardiothoracic surgery. St. Louis, MO: Mosby, 1991:221-236.
- Crawford E.S., Svensson L.G., Coselli J.S., et al. Aortic dissection and dissecting aortic aneurysms. Ann Surg 1988;208:254-273.[Medline]
- Mancini M.C., Cush E.M. Shunt control of bleeding after homograft replacement of the ascending aorta. Ann Thorac Surg 1999;67:1162-1163.[Abstract/Free Full Text]
- Vogt P.R., Akintürk H., Bettex D.A., Schmidlin D., Lachat M.L., Turina M.I. Modification of surgical aortaatrial shunts for inaccessible bleeding in aortic surgery. Thorac Cardiovasc Surg 2001;49:240-242.[Medline]
- Blum M., Panos A., Lichtenstein S.V., Salerno T.A. Modified Cabrol shunt for control of haemorrhage in repair of type A dissection of the aorta. Ann Thorac Surg 1989;48:709-711.[Abstract]
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Abstract
Introduction
