Asian Cardiovasc Thorac Ann 2006;14:35-37
© 2006 Asia Publishing EXchange Ltd
Femoral Artery Cannulation in Stanford Type A Aortic Dissection Operations
Xiao-Tong Hou, MD,
Yan-Qing Sun, MD,
Hong-Jia Zhang, MD,
Si-Hong Zheng, MD,
Yu-Yong Liu, MD,
Jian-Gang Wang, MD
Department of Cardiac Surgery, Beijing An Zhen Hospital, Capital University of Medical Science, Beijing, China
For reprint information contact: Xiao-Tong Hou, MD Tel: 86 10 6445 6384 Fax: 86 10 6838 9856 Email:houxiaotong{at}yahoo.com.cn, Department of Cardiac Surgery, Beijing An Zhen Hospital, Capital University of Medical Science, Beijing 100029, China.
 |
ABSTRACT
|
|---|
The aim of this study was to evaluate femoral artery cannulation in Stanford type A aortic dissection operations. Between March 1994 and December 2001, 88 patients with Stanford type A aortic dissection underwent surgery with cardiopulmonary bypass and perfusion through the femoral artery; 31 of them had deep-hypothermic circulatory arrest. False lumen perfusion was detected in 8 patients (9.1%). There were 4 (4.5%) cerebral events: 2 patients had diffuse cerebral injury, with one death; and 2 patients had hemiplegia, with one death. Six patients (8.0%) had delayed incision healing, with local infection in one. There was no lower extremity ischemia associated with femoral artery cannulation. It was concluded that retrograde perfusion through the femoral artery was effective for repair of aortic dissection, with a low risk of those cerebral events associated with a high mortality rate.
|
INTRODUCTION
|
|---|
Femoral artery cannulation is the standard method of cannulation for cardiopulmonary bypass (CPB) in Stanford type A aortic dissection operations. It ensures true-lumen cannulation, but has the disadvantages of retrograde perfusion, including potential cerebral hypoperfusion and dislodgment and retrograde embolization of luminal debris.1 Other problems associated with femoral artery cannulation include lower extremity ischemia and wound complications. Our experience of complications arising from femoral artery cannulation for Stanford type A aortic dissection operations was assessed.
|
PATIENTS AND METHODS
|
|---|
Between March 1, 1994 and December 31, 2001, 88 patients with Stanford type A aortic dissection underwent surgical repair with arterial perfusion through the femoral artery in Beijing An Zhen Hospital. The mean age was 43 ± 11 years (22–72 years). There were 70 males (79.5%) and 18 females (20.5%). Routinely, the left femoral artery was cannulated in 84 patients. Four patients had right femoral artery cannulation because of left femoral artery stenosis. A median sternotomy was performed in all patients. The ascending aorta was replaced in 84 patients, including a Bentall procedure in 38, aortic valve replacement in 19, and arch replacement in 8. The ascending aorta was repaired in 4 patients. The operations were performed under total circulatory arrest in 26 patients. Superior vena caval retrograde perfusion was used in 12 patients for cerebral protection.
Right radial artery pressure was monitored throughout the operation. The femoral artery was approached through an oblique incision made 1.5 cm above the groin in 62 patients, and through a longitudinal incision in 26 patients. The crural ligament was partially divided, and the femoral artery was mobilized. The artery was clamped proximally and distally after heparinization. A preclotted 8 mm graft was anastomosed end-to-side to a longitudinal arteriotomy with 5/0 Prolene (Ethicon Inc., Somerville, NJ, USA), and a 22F or 24F cannula was inserted into the graft. This fitted snugly and was secured with one heavy silk tie. The cannula was then attached to the arterial return tubing.
The chest was opened by sternotomy and both venae cavae were cannulated. Cardiopulmonary bypass was started, and a left ventricular vent was placed through the right superior pulmonary vein. If the heart became distended secondary to severe aortic insufficiency, the ascending aorta was crossclamped, the aorta was opened, and cardioplegia was perfused directly. If the tear was confined to the ascending aorta, the core temperature was cooled to 28°C; if the arch was involved, then the core temperature target was 18°C, and total circulatory arrest with retrograde cardioplegia was instituted. When the arch replacement or distal anastomosis was complete, a crossclamp was applied to the graft, CPB was resumed, and the patient was rewarmed. An appropriate procedure on the proximal aorta was then performed. After weaning from CPB, protamine was administered. The femoral graft was simply clamped and cut approximately 5 mm from the anastomosis. The graft was oversewn with 5.0 Prolene in two layers.
|
RESULTS
|
|---|
Thirteen patients died within 30 days of the operation (hospital mortality rate, 14.8%). The following complications were associated with femoral artery cannulation. False lumen perfusion was observed in 8 patients (9.1%). This happened at the time of crossclamping in 2 cases: the cannula was immediately moved to the ascending aorta; after the core temperature had reached 18°C, total circulatory arrest was started, and the appropriate procedures were carried out. In the other 6 patients, false lumen perfusion was observed after declamping; a cannula was inserted into the aortic graft immediately, and antegrade aortic perfusion was resumed.
There were 4 cerebral events (4/88, 4.5%). Diffuse cerebral injury was present in 2 patients, including one who had false lumen perfusion; both failed to awake and one died in the hospital. Cerebral emboli were found in 2 patients; both presented with hemiplegia, and one died. The mortality in those with cerebral events was 50%. There were 7 cases of local complications among the survivors (7/75, 9.3%). Prolonged incisional wound healing was found in 6 patients (6/75, 8.0%), including 4 (4/22, 18.2%) who had a longitudinal incision and 2 (2/53, 3.8%) who had an oblique incision. Local infection occurred in one of these patients. There was no extremity ischemia or embolism.
|
DISCUSSION
|
|---|
Femoral arterial perfusion with application of a distal ascending aortic crossclamp has been routinely used for the repair of Stanford type A aortic dissection. In an autopsy study, 42% of patients were found to be at risk of false lumen perfusion on crossclamp placement during retrograde femoral arterial perfusion.2 A study by Voci and colleagues3 showed that 11.1% of patients who underwent repair of type A aortic dissection had false lumen perfusion. Should this occur, the terminal area of decompression would then be the arch vessels. Extension of the dissection into the arch vessel could occur, and neurological injury may ensue. In our series, there were 8 patients (9.1%) with false lumen perfusion, and one of them died from diffuse cerebral injury. In addition, luminal debris may be washed into the arch vessels retrogradely, causing cerebral embolism. Several reports show the morbidity of cerebral embolism to be 14.5 –28%.1,4 Some have advocated initiation of femoral arterial perfusion or ascending aortic perfusion, followed by immediate cooling for circulatory arrest.5–6 After open inspection of the arch, distal repair is performed, and antegrade CPB is then re-instituted through aortic graft cannulation. The ascending aorta is crossclamped on the graft, and the proximal repair is completed. This technique is known as "open arch" repair.
In recent years, axillary artery cannulation in type A aortic dissection has been proposed.7 This technique is now accepted more widely and has some advantages over other cannulation methods. Right axillary artery cannulation perfuses the true lumen antegradely from the start of the operation, and it eliminates the extra step of having to cannulate the aortic graft. In a recent study, Shimazaki and colleagues8 reported that axillary artery cannulation may minimize cerebral complications in aortic operations. However, it also has some complications such as brachial plexus injury, axillary artery damage, and arm ischemia.9 The femoral artery cannulation technique used in our series did not cause lower extremity ischemia or thrombosis, and the method of decannulation is very easy. Furthermore, there were fewer patients with prolonged incisional wound healing when the oblique incision was used. It was concluded that arterial perfusion through the femoral artery for repair of aortic dissection is effective, and has a low risk of those cerebral events associated with a high mortality rate.
|
REFERENCES
|
|---|
- David TE, Armstrong S, Ivanov J, Barnard S. Surgery for acute type A aortic dissection. Ann Thorac Surg 1999;67:1999–2001.[Abstract/Free Full Text]
- Van Arsdell GS, David TE, Butany J. Autopsies in acute type A aortic dissection. Surgical implications. Circulation 1998;98(19 Suppl):II299–304.
- Voci P, Testa G, Tritapepe L, Menichetti A, Caretta Q. Detection of false lumen perfusion at the beginning of cardiopulmonary bypass in patients undergoing repair of aortic dissection. Crit Care Med 2000;28:1841–6.[Medline]
- Westaby S, Katsumata T, Vaccari G. Arch and descending aortic aneurysms: influence of perfusion technique on neurological outcome. Eur J Cardiothorac Surg 1999;15:180–5.[Abstract/Free Full Text]
- Laas J, Jurmann MJ, Heinemann M, Borst HG. Advances in aortic arch surgery. Ann Thorac Surg 1992;53:227–32.[Abstract]
- Lijoi A, Scarano F, Dottori V, Parodi E, Casali G, Bartolozzi F. Stanford type A aortic dissection. A new surgical approach. Tex Heart Inst J 1998;25:65–7.[Medline]
- Whitlark JD, Goldman SM, Sutter FP. Axillary artery cannulation in acute ascending aortic dissections. Ann Thorac Surg 2000;69:1127–9.[Abstract/Free Full Text]
- Shimazaki Y, Watanabe T, Takahashi T, Minowa T, Inui K, Uchida T, et al. Minimized mortality and neurological complications in surgery for chronic arch aneurysm: axillary artery cannulation, selective cerebral perfusion, and replacement of the ascending and total arch aorta. J Card Surg 2004;19:338–42.[Medline]
- Sabik JF, Nemeh H, Lytle BW, Blackstone EH, Gillinov AM, Rajeswaran J, et al. Cannulation of the axillary artery with a side graft reduces morbidity. Ann Thorac Surg 2004;77:1315–20.[Abstract/Free Full Text]
TOP
ABSTRACT
INTRODUCTION
