Asian Cardiovasc Thorac Ann 2005;13:88-89
© 2005 Asia Publishing EXchange Ltd
An Alternative and Safer Method for Aortic Decannulation
Maninder S Kalkat, MCh,
Jitender M Parmar, FRCS
Department of Cardiothoracic Surgery, North Staffordshire Royal Infirmary, West Midlands, UK
For reprint information contact: Maninder S Kalkat, MCh Tel: 44 1922 624 653 Fax: 44 1782 552 001 Email: mankalkat{at}hotmail.com, 12 Redruth Close, Walsall, West Midlands WS5 3ER, UK.
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ABSTRACT
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The removal of an aortic cannula at the termination of cardiopulmonary bypass is occasionally associated with complications like bleeding, atheroembolism and dissection. An alternative method to decannulate using a side-biting non-crushing clamp is suggested to mitigate against these complications.
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INTRODUCTION
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The aortic cannulation for the conduct of extracorporeal circulation during the cardiac surgery and subsequent decannulation is usually a routine affair. Various manoeuvres and methods are used, according to one’s preference to remove the cannula safely and avoid the complications.
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METHOD
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A single purse string suture is placed around the usual soft site in the ascending aorta using 3-0 Ethibond suture. After heparinization, a longitudinal aortotomy is performed in the center of the purse-string suture. An aortic cannula of an appropriate size and one with a short straight tip is then introduced through the aortotomy in a gentle manner, ensuring the bevel of the cannula is facing antegradely. After the termination of the bypass and before the administration of protamine, the aortic pipe is removed. The snugger securing the purse-string suture is released. A fine side-biting clamp is applied on either side of the aortic cannula and, as the jaws are closed, the cannula slides out effortlessly. The two edges of the aortotomy site are inspected, any atheromatous material and debris are removed. The incision is closed using over-running prolene 3-0 suture picking up the full thickness of the aortic edges, with special care to include the intima. The side-biting clamp is removed and the purse string is tied to further reinforce the closure (Figure 1
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Figure 1. Demonstration of the sequence of aortic decannulation (A) the aortic cannula secured with a single purse-string suture; (B) the cannula sliding out of the aorta as the jaws of the side-biting clamp are approximated; (C) the side-biting clamp securely applied; and (D) the final result after tying the purse-string suture.
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DISCUSSION
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Aortic decannulation after cardiopulmonary bypass is associated with various complications like bleeding, thromboembolism and dissection.1 The bleeding due to disruption of the purse strings is occasionally difficult to control, especially in the atheromatous fragile aorta seen in the elderly population. The loose atheromatous material and shreds of the intimal tissue created during the cannulation procedure can often be seen protruding through the aortotomy site after removing the cannula. Simple tying of the purse-string suture can possibly result in embolization of this loose material. Similarly, there is a possibility of dissection initiating at the site of decannulation from the intimal flap raised during the insertion of the aortic cannula.2
There are reports of a pseudoaneurysm forming at the cannulation site, probably as a result of failure to approximate the various layers of the aortic wall.3 The advantage of the method described is that it is easy to apply and is not dependent on the assistant. The cannula is removed in a controlled manner without fear of the purse-string suture cutting through the aortic wall. Any loose debris protruding out of the aortotomy site can be visualized and removed. The full-thickness suture can be passed through the opposing walls of the aorta, tacking all the layers together and hence minimizing the danger of dissection or aneurysm formation.
The disadvantage of this method is the possibility of trauma to the aortic wall and dislodgement of plaque or any atheromatous material during the application of the side-biting clamp.
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CONCLUSION
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Removal of an aortic cannula with the aid of a side-biting clamp is an easy and safe method. It can help in eliminating the occasionally encountered complications associated with the conventional technique of decannulation and closing the aortotomy site. We recommend that readers be aware of this technique which can be used in conjunction with the conventional method in appropriate circumstances.
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REFERENCES
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- Ura M, Sakata R, Nakayama Y, Goto T. Ultrasonographic demonstration of manipulation-related aortic injuries after cardiac surgery. J Am Coll Cardiol
2000;35:1303–10.[Abstract/Free Full Text]
- Razzouk A, Gundry S, Wang N, Heyner R, Sciolaro C, Van Arsdell G, et al. Pseudoaneurysms of the aorta after cardiac surgery or chest trauma. Am Surg
1993;59:818–23.[Medline]
- Aoyagi S, Tayama E, Nishimi M, Chihara S, Onizuka S, Fukunaga S. Aortic dissections complicating open cardiac surgery: report of three cases. Surg Today
2000;30:1022–5.[Medline]
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ABSTRACT
INTRODUCTION
