Ann Thorac Surg 2004;78:2196-2198
© 2004 The Society of Thoracic Surgeons
How to do it
Distal Aortic Perfusion During Aortic Arch Reconstruction: Another Tool for the Aortic Surgeon
Charles T. Klodell, MDa,*,
Philip J. Hess, MDa,
Thomas M. Beaver, MDa,
Dale Clark, CCPa,
Tomas D. Martin, MDa
a Division of Cardiothoracic Surgery, University of Florida College of Medicine Health Science Center, Gainesville, Florida, USA
Accepted for publication October 16, 2003.
* Address reprint requests to Dr Klodell, University of Florida, PO Box 100286, Gainesville, FL 32610-0286, USA
cklodell{at}ufl.edu
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Abstract
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Complex aortic arch reconstruction remains one of the greatest challenges facing cardiothoracic surgeons today. Deep hypothermic circulatory arrest is the most common technique for open arch replacement. Either antegrade or retrograde cerebral perfusion is often utilized in an attempt to decrease neurologic complications. In addition to cerebral perfusion, we have employed continuous perfusion of the thoracic aorta to minimize spinal cord, visceral, and lower extremity ischemia. This approach does not significantly increase the complexity of the operative procedure while reducing the ischemic time of critical areas, which may lead to improved patient outcomes.
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Introduction
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Cerebral protection and adequate perfusion to prevent neuropsychologic dysfunction is of paramount importance during aortic arch and proximal descending aortic reconstruction. Currently, the perfusion techniques used to prevent cerebral damage include deep hypothermia circulatory arrest (DHCA), selective cerebral perfusion (SCP), and retrograde cerebral perfusion (RCP) [1–4]. The improvement of these perfusion techniques has decreased the mortality rate from 50% in the early years of aortic surgery to 4.8% in more recent studies [5, 6]. Even in light of these perfusion advances, arch reconstruction is still associated with significant morbidity [7]. We have performed a modified perfusion technique combining CP and distal aortic perfusion during complex aortic arch reconstruction. This technique is equally feasible with both contemporaneous antegrade cerebral perfusion and distal aortic perfusion, or retrograde cerebral perfusion combined with distal aortic perfusion. It serves to maintain perfusion to the spinal cord, viscera, and lower extremities during the period of open arch repair.
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Technique
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This technique can be applied in cases where only arch replacement is required, or in cases where coronary artery bypass grafting (CABG) or valve replacement (VR) is to be performed in conjunction with aortic arch replacement. A median sternotomy is performed, and cannulation sutures are placed. If epiaortic ultrasound demonstrates a favorable site, we choose to cannulate the aneurysm directly in most cases (Fig 1) A two-stage venous cannula is placed in the right atrium and inferior vena cava. For RCP, the superior vena cava (SVC) is cannulated with a 20/20 two-stage pediatric venous cannula. An umbilical tape tourniquet is placed on the proximal SVC. If the technique is to be used with "double antegrade perfusion" (ACP), balloon tipped perfusion catheters are prepared for insertion in the cerebral vasculature. Both the patient and the pump are loaded with aprotinin, and bypass is initiated when an activated clotting time is confirmed to be greater that 800 seconds. Cooling is immediately initiated, with a target bladder temperature of 18 degrees centigrade. The aorta is clamped after initiation of bypass, and cardioplegia is administered antegrade and retrograde to achieve diastolic arrest of the heart. Retrograde cardioplegia is reinstilled at 20-minute intervals. If a CABG is to be performed, the distal anastomosis can be completed during cooling. Similarly, valves that are to be replaced can be excised and sized during cooling. An appropriate size graft for arch replacement is selected and prepared. When the bladder temperature reaches 18 degrees centigrade, and electroencephalography is silent, circulatory arrest is initiated. The aortic cannula is removed and the aortic arch is expeditiously opened. The aortic perfusion line is attached to an aortic direct balloon occlusion cannula (ADIC 222, US Surgical, Norwalk, CT). This cannula is passed through the lumen of the Dacron graft and into the proximal descending aorta (Fig 2). The balloon is filled with saline and flow is reestablished into the descending aorta. Cerebral perfusion is facilitated with a preprimed 
inch tubing line attached to the cannula previously placed in the SVC for RCP, or to balloon tipped catheters for ACP. The CP tubing is attached to the blood plegia outlet of the oxygenator and placed on a separate roller pump. When utilizing CP and ADIC simultaneously with two separate pumps off the same oxygenator, the primary aortic line is used to maintain the higher systemic flow through the balloon cannula. Flow through this line must be higher than the CP to avoid "pulling" air across the oxygenator. With the main pump flowing through the descending aorta at a rate of 1.5 to 2 L/min, the auxiliary pump flow to the CP is initiated at 0.25 to 0.35 L/min. For RCP, the SVC is occluded proximally with the tourniquet. The venous drainage cannula is left in place to collect the return from the systemic perfusion. Utilizing an "open arch" technique, the distal end of the graft is anastomosed to the proximal descending aorta while antegrade flow is maintained via the balloon tipped cannula (Fig 3). An island patch anastomosis of the innominate, left carotid, and left subclavian arteries is constructed to the superior aspect of the graft while antegrade flow is maintained (Fig 4). The suture lines can be tested for hemostasis by transiently deflating the ADIC balloon while the proximal graft is occluded around the cannula. Once the anastomosis is deemed satisfactory, the pump flow is transiently stopped. The ADIC and CP cannulas are withdrawn, and an aortic perfusion cannula is inserted into the Dacron graft. Perfusion is slowly reinitiated, allowing effective evacuation of air from the Dacron graft. A clamp is placed across the Dacron graft proximal to the aortic cannula. During rewarming the proximal aortic graft anastomosis, proximal bypass graft anastomosis, and valve replacements are accomplished as indicated. The aortic cross clamp is removed following evacuation of intracardiac air. The patient is separated from bypass after obtaining a bladder temperature of 36°C.
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Fig 1. If epiaortic ultrasound demonstrates a favorable site, the aneurysm is cannulated directly. The arrow demonstrates the direction of blood flow in the aortic cannula. The tube surrounding the arrow represents the aortic cannula placed directly into the aorta.
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Fig 2. The ADIC balloon tipped cannula is placed through the Dacron graft and inflated in the proximal descending aorta.
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Fig 4. The innominate, carotid, and subclavian vessels are implanted as an island patch to the Dacron graft while distal perfusion is maintained.
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An alternate approach with similar effect involves arterial inflow at the femoral artery in conjunction with a balloon occlusion device in the thoracic aorta. This approach is useful when epiaortic ultrasound of the ascending aorta reveals significant atheromatous debris. With the femoral perfusion technique, a balloon occlusion device is used in place of the ADIC perfusion cannula to occlude the proximal thoracic aorta. This modification of our technique allows for easier manipulation of cannulas during circulatory arrest, as well as lower cost, in patients that can be more safely perfused via the femoral artery.
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Comment
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Complex aortic arch reconstruction poses significant challenges to the surgeon, as well as risk of significant morbidity to the patient. Current perfusion techniques are greatly improved as aortic experience has evolved, but still are associated with significant pitfalls. While some method of constant cerebral flow is utilized in most of these cases, this is not the norm for the distal aorta. The technique described allows continuance of the cerebral protection, with the added benefit of maintaining antegrade flow to the distal aorta, spinal cord, viscera, and lower extremities. Experience with this technique leads to technical facility with the cannula exchange procedure, resulting in a very brief duration of circulatory arrest. We believe this technique can serve as a valuable tool in the armamentarium of aortic surgeons. Certainly, randomized prospective trials to evaluate the benefit of continuous distal aortic perfusion during arch reconstruction are warranted.
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References
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- Deeb GM, Jenkins E, Bolling SF, et al. Retrograde cerebral perfusion during hypothermic circulatory arrest reduces neurologic morbidity. J Thorac Cardiovasc Surg. 1995;109:259–268[Abstract/Free Full Text]
- Sakurada T, Kazui T, Tanaka H, et al. Comparative experimental study of cerebral protection during aortic arch reconstruction. Ann Thorac Surg. 1996;61:1348–1354[Abstract/Free Full Text]
- Alamanni F, Agrifoglio M, Pompilio G, et al. Aortic arch surgery: pros and cons of selective cerebral perfusion. J Cardiovasc Surg. 1995;3:31–37
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- Aoyagi S, Akashi H, Kubota Y, et al. Surgical treatment of aneurysms of the aortic arch using a simplified selective cerebral perfusion technique. Thorac Cardiovasc Surg. 1994;42:279–284[Medline]
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Abstract
Introduction
