Echocardiographic comparison of the standard end-hole cannula,the soft-flow cannula,and the dispersion cannula during perfusion into the aortic arch

BACKGROUND: Dislodgement of aortic arch atheroma caused by a perfusion "jet" from the aortic cannula may be a major cause of atheroemboli during coronary artery surgery when using cardiopulmonary bypass (CPB). Two very different cannulas, the Soft-Flow aortic cannula and the Dispersion cannula, which have been designed to reduce exit velocity (cm/s) during perfusion, are compared with a standard steel tip cannula and to each other. METHODS: To demonstrate any significant differences transesophageal echocardiography (TEE) was used to measure exit velocity of each cannula at a distance of 1, 2, and 3 cm from the tip and compare flow morphology within the aortic arch. Nine patients in whom the cannula tip could be identified and colored Doppler imaging could demonstrate representative morphology were randomly assigned into one of three groups of 3 patients each: group I, a standard steel-tip end-hole cannula (7.3 mm); group II, the Soft-Flow cannula (8.0 mm); and group III, the Dispersion cannula (8.0 mm). RESULTS: The standard steel tip cannula demonstrated a long narrow perfusion jet. The Soft-Flow cannula morphology was made up of multiple smaller exiting jets. The Dispersion cannula demonstrated a broad wedge-shaped perfusion pattern. Perfusion hemodynamics (cardiopulmonary bypass hematocrit in d/L, cardiopulmonary bypass blood flow in L/m, mean arterial pressure during cardiopulmonary bypass mm Hg, and perfusion line pressure in mm Hg) were not significantly different between each group. The mean velocities between group I (318 +/- 63 cm/s at 1 cm, 296 +/- 60 cm/s at 2 cm, 271 +/- 85 cm/s at 3 cm) and group II (351 +/- 31 cm/s at 1 cm, 240 +/- 103 cm/s at 2 cm, 171 +/- 120 cm/s at 3 cm) were not statistically different. Group III (the Dispersion cannula) demonstrated significantly reduced velocities (174 +/- 22 cm/s at 1 cm, 138 +/- 23 cm/s at 2 cm, 90 +/- 36 cm/s at 3 cm) when compared with the other two groups (p < 0.05, analysis of variance). CONCLUSIONS: The Dispersion cannula is significantly different with a lower perfusion velocity and the elimination of the exiting jet or jets. This cannula warrants further clinical study as it may reduce atheroemboli during cardiopulmonary bypass.     

Off-pump complete pericardiectomy for an unusual case of annular constrictive pericarditis

The optimal cannulation site in repair of DeBakey type I aortic dissection is controversial, and malperfusion during cardiopulmonary bypass is facilitated by retrograde flow. We propose the use of a long arterial cannula through the femoral artery to achieve a proximal antegrade perfusion. The tip of the cannula is placed in the true lumen of the distal aortic arch through the common femoral artery (Seldinger technique and transesophageal echography guidance). In 9 patients, there was one case of operative mortality (cardiac death), and no cases of perioperative stroke, bowel ischemia, severe renal failure, or local complications. Proximal perfusion can achieved rapidly and through an easily accessible site.     

Isolated myocardial perfusion during arch repair

Repair of coarctation of the aorta with severe hypoplasia of the aortic arch or interrupted aortic arch was performed in 5 patients using a modification of the usual technique that consisted of isolated myocardial perfusion during arch repair. The aortic cross-clamp was placed on the ascending aorta distal to the aortic cannula. Cardiopulmonary bypass flow was reduced to about 10% of full flow, achieving a line pressure of 35 to 45 mm Hg to keep the heart perfused and beating during arch repair. Once the aortic arch was repaired, total body perfusion was continued as usual and intracardiac repair was performed. Isolated myocardial perfusion for aortic arch reconstruction reduces myocardial ischemic time.     

Hydrodynamic evaluation of axillary artery perfusion for normal and diseased aorta

Axillary artery perfusion is an attractive alternative to reduce the frequency of atheroembolism in extensive atherosclerotic aorta and aortic aneurysms. This study was conducted to evaluate the flow dynamics of axillary artery perfusion. Transparent glass models of a normal aortic arch and an aortic arch aneurysm were used to evaluate hydrodynamic properties. Streamline analysis and distribution of the shear stress was evaluated using a particle image velocity method. In the normal aortic arch model, rapid flow of 80 cm/s from the right axillary artery ran out from the brachiocephalic artery and grazed the lesser curvature of the aortic arch. There was secondary reversed flow in the ascending aorta. Flow from left axillary perfusion went straight to the descending aorta. In the aortic arch aneurysm model, flow from both axillary arteries hit the lesser curvature of the aortic arch and went into the ascending aorta with vortical flow. Distribution of shear stress was high along the jet from the ostium of the brachiocephalic artery and left subclavian artery. Flow in the aortic arch and the ascending aorta was unexpectedly rapid. Special care must be taken when the patient has frail atheroma around arch vessels or the lesser curvature of the aortic arch during axillary artery perfusion.     

Three-region perfusion strategy for aortic arch reconstruction in the Norwood

We describe a new method of selective regional perfusion during arch reconstruction in the Norwood procedure. The strategy involves direct sequential perfusion of the coronary and splanchnic circulations coupled with continuous cerebral perfusion, while repairing the arch in a distal to proximal fashion. This technique provides the potential for decreased coronary and splanchnic ischemic times, which in combination with continuous selective cerebral perfusion may further allow for warmer operating temperatures and decreased overall bypass times.     

Anterolateral Thoracotomy for Distal Aortic Arch Disease

Purpose Optimal exposure and antegrade arterial perfusion are keys to avoiding complications in the repair of distal aortic arch disease. To achieve these ends, we performed distal aortic arch repair through a left anterolateral thoracotomy while also using axillary artery perfusion. Methods From Mach 1998 to December 2004, 28 patients (23 men and 5 women, age 65.2 ± 12.0 years) underwent a distal aortic arch repair through a left anterolateral thoracotomy. All cases had atherosclerotic aneurysms. Emergency surgery was performed in 1 of these cases (1/28, 3.6%) with an aortic rupture. The right axillary artery was used for arterial perfusion in all cases. Results No perfusion problems occurred during surgery, and the left anterolateral thoracotomy approach provided an excellent view of both the aortic arch and descending aorta. There was no hospital mortality. Morbidity included one incident of transient convulsion without computed tomographic evidence of an embolism and one incident of heart failure that required temporary mechanical support. No other significant event or morbidity occurred related to the surgical methods. There was no late death during the 1 to 81-month follow-up. Conclusion A left anterolateral thoractomy provides an ideal view of distal aortic arch disease, and antegrade arterial perfusion is effective in the prevention of retrograde embolism. These results suggest this treatment modality to be a reliable alternative approach for the repair of distal aortic arch disease.     

Total aortic arch aneurysm repair using a stent graft without cardiac or cerebral ischemia

A 74-year-old man with an aortic arch aneurysm and a chronic type IIIb aortic dissection underwent total aortic arch repair without cerebral or cardiac ischemia. After confirming no atheromatous change in the ascending aortic wall, a custom-designed 4-limbed graft, prepared for both arterial return of cardiopulmonary bypass and reconstruction of the arch vessels, was anastomosed onto the right side of the ascending aorta. The 3 arch vessels were then bypassed sequentially during systemic cooling and monitoring cerebral perfusion with near-infrared oxymetry. After aortic cross-clamping, a stent graft was inserted into the distal arch from the distal ascending aorta, maintaining cerebral and cardiac perfusion. This procedure is indicated especially in a high-risk patient who has an aortic arch aneurysm without severe atheromatous change in the ascending aorta and the arch vessels.     

Surgical treatment of aneurysm or dissection involving the ascending aorta and aortic arch, utilizing circulatory arrest and retrograde cerebral perfusion

Recently we replaced the ascending aorta and aortic arch in 8 patients with aneurysm or dissection, using profound hypothermic circulatory arrest with retrograde cerebral perfusion. There were no operative deaths. Open aortic anastomosis facilitated repair of the aortic arch without clamping the arch tributaries, and embolism due to particulate debris from clamping of the arch vessels was eliminated. Retrograde cerebral perfusion during profound hypothermic circulatory arrest is a simplified technique that may protect the brain. This method offers advantages over previously described methods, particularly in obviating dissection of the arch tributaries and the clamping thereof, and in protecting the central nervous system.     

The efficacy of non-clamping selective cerebral perfusion in distal aortic arch aneurysm repair: Report of a case

Successful repair of a distal aortic arch aneurysm without aortic cross-clamping was carried out in a 74-year-old man, using a combination of special separate cerebral perfusion and retrograde coronary perfusion, termed non-clamping selective cerebral perfusion. We believe that satisfactory results following aortic arch surgery in elderly patients can only be achieved through the prevention of emboli derived from an aortic cross-clamping site, and shortened ischemic time of the vital organs.     

Selective cerebro-myocardial perfusion in complex congenital aortic arch pathology: a novel technique

Simultaneous cerebro-myocardial perfusion has been described in neonatal and infant arch surgery, suggesting a reduction in cardiac morbidity. Here reported is a novel technique for selective cerebral perfusion combined with controlled and independent myocardial perfusion during surgery for complex or recurrent aortic arch lesions. From April 2008 to April 2011, 10 patients with arch pathology underwent surgery (two hypoplastic left heart syndrome [HLHS], four recurrent arch obstruction, two aortic arch hypoplasia + ventricular septal defect [VSD], one single ventricle + transposition of the great arteries + arch hypoplasia, one interrupted aortic arch type B + VSD). Median age was 63 days (6 days-36 years) and median weight 4.0 kg (1.6-52). Via midline sternotomy, an arterial cannula (6 or 8 Fr for infants) was directly inserted into the innominate artery or through a polytetrafluoroethylene (PTFE) graft (for neonates <2.0 kg). A cardioplegia delivery system was inserted into the aortic root. Under moderate hypothermia, ascending and descending aorta were cross-clamped, and "beating heart and brain" aortic arch repair was performed. Arch repair was composed of patch augmentation in five, end-to-side anastomosis in three, and replacement in two patients. Average cardiopulmonary bypass time was 163 ± 68 min (71-310). In two patients only (one HLHS, one complex single ventricle), a period of cardiac arrest was required to complete intracardiac repair. In such cases, antegrade blood cardioplegia was delivered directly via the same catheter used for selective myocardial perfusion. Average time of splanchnic ischemia during cerebro-myocardial perfusion was 39 ± 18 min (17-69). Weaning from cardiopulmonary bypass was achieved without inotropic support in three and with low dose in seven patients. One patient required veno-arterial extracorporeal membrane oxygenation. Four patients, body weight <3.0 kg, needed delayed sternal closure. No neurologic dysfunction was noted. Renal function proved satisfactory in all, while liver function was adequate in all but one. The present experience suggests that selective and independent cerebro-myocardial perfusion is feasible in patients with complex or recurrent aortic arch disease, starting from premature newborn less than 2.0 kg of body weight to adults. The technique is as safe as previously reported methods of cerebro-myocardial perfusion and possibly more versatile.     

Surgery for distal aortic arch aneurysm with a patent left internal mammary-to-coronary artery graft; report of a case

We report a case of 62-year-old male who suffered from a distal aortic arch aneurysm developed 5 years after coronary artery bypass grafting (CABG). Preoperative angiography revealed a distal arch aneurysm and a patent left internal mammary artery (LIMA) graft. Graft replacement of the total aortic arch was performed using a 4 branched graft. After the re-median sternotomy, cardiopulmonary bypass was established with ascending aortic perfusion and right atrium (RA) drainage. Myocardial protection was achieved with root cold blood cardioplegia and LIMA continuous cold blood perfusion. Distal anastomosis was performed under selective cerebral perfusion and during deep hypothermic circulatory arrest. Postoperative course was satisfactory and the patient was discharged without complications.     

Total aortic arch grafting via median sternotomy using integrated antegrade cerebral perfusion

BACKGROUND: In aortic arch grafting, antegrade cerebral perfusion prolongs the safe time of arch exclusion. However, there are the problems of cerebral embolism and distribution of the cerebral perfusion. We describe and analyze mortality and cerebral complications in patients undergoing total arch grafting using our refined technique. METHODS: Between June 1994 and March 2002, 100 consecutive patients underwent total arch grafting through median sternotomy. There were 49 atherosclerotic aneurysms and 51 aortic dissections. Fifty-four patients were operated on an emergency basis because of rupture or acute type A dissection. We conducted total arch grafting using hypothermic antegrade cerebral perfusion from every cervical vessel. Carbon dioxide gas was added to the cerebral perfusion in order to inhibit the increase in the cerebral vascular resistance during hypothermic cerebral perfusion. RESULTS: Hospital mortality was 4%. The causes of death were dysarrhythmia (n = 1), mesenteric necrosis (n = 1), and preoperative cardiac arrest (n = 2). On univariate analysis, preoperative shock and concomitant cardiac procedures were risk factors for hospital death. The rate of postoperative neurologic damage was 5%. Two patients suffered from cerebral infarction. Temporary neurologic dysfunction occurred in 3 patients. On univariate analysis, emergency surgery was a risk factor for postoperative neurologic damage. On multivariate analysis, there was no significant independent predictor of hospital mortality and neurologic damage. Actuarial survival at 96 months was 66.4 +/- 9.1%, and freedom from aortic accidents (reoperation, rupture, and cholesterol embolism) was 74.9 +/- 7.9%. CONCLUSIONS: The early- and long-term results of total arch grafting using integrated antegrade cerebral perfusion were found to be satisfactory.     

Total arch replacement using antegrade selective cerebral perfusion with right axillary artery perfusion.

OBJECTIVE: Right axillary artery (AxA) perfusion, which can prevent cerebral embolism caused by retrograde perfusion via the femoral artery (FA), was used for selective cerebral perfusion (SCP) as well as cardiopulmonary bypass (CPB) in aortic arch repair. We review the outcome of aortic arch surgery using SCP with right AxA perfusion to clarify its efficacy. METHOD: Between 1998 and 2002, 120 patients underwent aortic arch repair using SCP with right AxA perfusion. The mean age was 69+/-10 years. Aneurysms were atherosclerotic in 79, dissecting in 32, and others in nine patients. Twenty of them (16.7%) required emergency surgery. CPB was initiated with right AxA and FA perfusion, and following SCP was established using right AxA and left common carotid artery perfusion. RESULTS: With right AxA perfusion, hospital mortality was 5.8%. Multivariate analysis showed only ruptured aneurysm was an independent determinant for hospital mortality. Permanent neurological dysfunction developed in one patient (0.8%), while seven (5.8%) suffered from temporary one. In univariate analysis, SCP time, stenosis of the carotid arteries, past history of cerebrovascular events, and atherosclerotic aneurysm were not related to temporary neurological deficits CONCLUSION: Right AxA perfusion in conjunction with SCP is a safe and useful alternative for brain protection in total arch replacement.     

Arch repair with unilateral antegrade cerebral perfusion.

OBJECTIVE: Several antegrade cerebral perfusion techniques with differing neurological outcomes are employed for aortic arch repair. This study demonstrates the clinical results of aortic arch repair with unilateral cerebral perfusion via the right brachial artery. METHODS: Between January 1996 and March 2004, 181 patients underwent aortic arch repair via the right upper brachial artery with the use of low-flow (8-10 ml/kg per min) antegrade selective cerebral perfusion under moderate hypothermia (26 degrees C). Mean patient age was 58+/-12 years. Presenting pathologies were Stanford type A aortic dissection in 112, aneurysm of ascending and arch of aorta in 67, and isolated arch aneurysm in two patients. Ascending and/or partial arch replacement was performed in 90 patients and ascending and total arch replacement in 91 patients (including 27 with elephant trunk). In a subset of patients, renal and hepatic effects of ischemic insult were assessed. Free hemoglobin and lactate dehydrogenase levels were measured pre and postoperatively to identify hemolytic effects of brachial artery cannulation. RESULTS: Mean antegrade cerebral perfusion time was 36+/-27 min. Three patients with acute proximal dissection died due to cerebral complications. One patient had transient right hemiparesis. Total major neurological event rate was 2.2%. Brachial artery was able to carry full cardiopulmonary bypass flow with mild hemolysis. Renal and hepatic tests showed no deleterious effects of limited ischemia at moderate hypothermia. CONCLUSIONS: Arch repair with antegrade cerebral perfusion through right brachial artery has excellent neurological results, provides technical simplicity and optimal repair without time restraints, does not necessitate deep hypothermia and requires shorter CPB and operation times.     

A successful surgical case of aortic arch aneurysm associated with aortic regurgitation

A 57-year-old male patient with aortic regurgitation and aneurysm of the ascending aorta and the aortic arch underwent aortic valve replacement and graft replacement from the ascending aorta to the aortic arch. The operation was done using cardio-pulmonary bypass and selective cerebral perfusion with deep hypothermia. Postoperative DSA revealed no dilatation of the sinus Valsalva and a good configuration of the anastomosis. It seems that selective cerebral perfusion with deep hypothermia is a safe method to prevent cerebral damage in a case of arch aneurysm.     

Management of complex tracheo-aortic fistula following neonatal tracheal reconstruction

We describe an unusual case of tracheo-aortic fistula, which occurred after tracheal surgery and tracheal stenting. The management of this complex case and the surgical technique used for repair are discussed and illustrated. Repair of the aortic arch was accomplished using a modified technique of regional low-flow perfusion, similar to that described for neonatal aortic arch reconstruction. This strategy allowed maintenance of cerebral, myocardial, and systemic perfusion during arch repair, thus avoiding total circulatory arrest.     

Anteroaxillary Thoracotomy Facilitates the Use of Retrograde Cerebral Perfusion in Distal Aortic Arch Reconstruction

Anteroaxillary thoracotomy in a 45-degree position provides an ideal view of the distal aortic arch and also makes direct superior vena caval cannulation possible for retrograde cerebral perfusion. This approach is especially useful in cases in which retrograde cerebral perfusion is indicated as an adjunct to deep hypothermic circulatory arrest in repair of the distal aortic arch.     

Novel technique for aortic arch surgery under mild hypothermia

We present our initial experience in 5 patients for open aortic arch repair with continuous antegrade perfusion of the brain and of the lower body by means of direct cannulation of the right axillary artery and of the descending aorta with a venous cannula (DLP 91037 cannula [Medtronic Inc, Minneapolis, MN]) for systemic perfusion under mild hypothermia (30 degrees C). This mode of perfusion allows safe open repair of the aortic arch, short aortic cross clamping, and CPB times associated to all the known advantages of the mild hypothermia; this technique could have the potential to be generally applicable in surgeries for aortic arch repairs after further evaluation.     

Recent surgical treatment for patients with true aortic arch aneurysm

From december 1996 to april 1999, 25 patients with true aortic arch aneurysm underwent aortic arch aneurysm repair using selective cerebral perfusion. There were 17 males and 8 females ranging in age from 62 to 79 years (mean 71 years). Orikaesi method was used in the procedure of distal anastomosis for complete aortic arch replacement with a prosthetic graft. This technique allowed us a simple approach to the lesion and the easy additional stitch. The average duration of extracorporeal circulation, aortic crossclamping, selective cerebral perfusion were 269 minutes, 140 minutes, and 122 minutes, respectively, under 19.3 degrees C of lowest esophageal temperature. There were no cases complicated with postoperative low output syndrome and cerebrovascular accident, and no hospital mortality. Replacement of the aortic arch using selective cerebral perfusion is a safe procedure with acceptable hospital mortality.     

An elderly case of ruptured aortic arch aneurysm with hemorrhagic cardiac tamponade

We reported a case of successful aortic arch replacement using selective cerebral perfusion for ruptured distal aortic arch aneurysm (DAAA) with cardiac tamponade. A 80-year-old man who had preoperative episode of severe chest pain. Computed tomography showed saccular DAAA and pericardial effusion. He was diagnosed as ruptured DAAA with hemorrhagic cardiac tamponade. We performed urgent graft replacement of the aortic arch using selective cerebral perfusion. Postoperatively he had no complication. Thirty days after the operation he was discharged from the hospital and he is now leading a normal life.