Asian Cardiovasc Thorac Ann 2007;15:528-530
© 2007 Asia Publishing EXchange Ltd
Safe Innominate Artery Cannulation for Cardiopulmonary Bypass in Neonates
Antonio F Corno, MD,
Marco Pozzi, MD
Royal Liverpool Children’s NHS Trust, Alder Hey, Liverpool, United Kingdom
For reprint information contact: Antonio F Corno, MD Tel: 44 151 252 5713 Fax: 44 151 252 5643 Email: Antonio.Corno{at}rlc.nhs.uk, Cardiac Unit, Royal Liverpool Children’s NHS Trust, Alder Hey, Eaton Road, Liverpool L12 2AP, United Kingdom.
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ABSTRACT
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To reduce the neurological complications of deep hypothermic circulatory arrest, continuous cerebral perfusion was introduced, either by direct innominate artery cannulation or by a tubular prosthesis. This second option, used in our clinical experience, has been extended to applications other than aortic arch reconstruction, to facilitate cardiopulmonary bypass in small neonates (< 3.0 kg) with complex congenital heart defects, and to facilitate postoperative extracorporeal membrane oxygenation.
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INTRODUCTION
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Deep hypothermic circulatory arrest (DHCA) has been used since the beginning of cardiac surgery for cardiopulmonary bypass (CPB) in pediatric patients requiring aortic arch reconstruction. Despite many changes in CPB techniques developed to prevent neurological sequelae, complications including seizures, psychological and developmental impairments are still observed after DHCA.1 To reduce the neurological complications of DHCA, continuous cerebral perfusion was introduced to avoid interrupting cerebral blood flow during cardiac surgery.2 Regional cerebral perfusion has been adopted by an increasing number of units over the last few years.3–5 Continuous regional cerebral perfusion can be achieved either by direct innominate artery cannulation or by a polytetrafluorethylene (PTFE) tubular prosthesis attached end-to-side to the innominate artery.2–5 This second option was used in our clinical experience, and the technique has been extended to applications other than aortic arch reconstruction, to facilitate CPB in neonates with complex congenital heart defects.
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TECHNIQUE
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Through a conventional median sternotomy, the innominate artery cephalad to the innominate vein is dissected free and controlled with a vessel loop. During a short period (< 10 min) of longitudinal application of a vascular clamp for longitudinal incision on the anterior aspect of the innominate artery, a 3-mm thin-walled tubular PTFE prosthesis, approximately 10 cm long, is anastomosed end-to-side to the innominate artery with a running 8/0 monofilament suture (Figure 1
). After declamping the innominate artery, the PTFE prosthesis is flushed with heparinized saline, and the free end is connected to the arterial cannula. After de-airing without active suction on the arterial cannula to avoid air suctioning, heparin is given and the arterial cannula is connected to the arterial end of the CPB circuit. The arterial cannula connected to the tubular prosthesis is then fixed out of the operative field (Figure 2). Venous cannulation is performed, and CPB is started at a flow rate of 2.4 L · m–2 · min–1 and hematocrit of 25%–30%, which are maintained throughout the entire procedure, even when the temperature is reduced to 22°C–24°C during aortic arch reconstruction. Antegrade blood cardioplegia is given via a needle in the ascending aorta. At the end of the surgical procedure, after reversal of heparin, the PTFE tubular prosthesis is closed with metal clips and divided 2 cm from its anastomosis with the innominate artery, avoiding sutures and potential damage to the artery. If required in the immediate postoperative period, the clips are removed, the PTFE tubular prosthesis is flushed and safely connected to an arterial cannula for extracorporeal membrane oxygenation assistance.
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Figure 1. Intraoperative photograph showing (A) the longitudinal application of a vascular clamp on the innominate artery and (B) a 3-mm thin-walled tubular prosthesis anastomosed end-to-side to the innominate artery.
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Figure 2. Intraoperative photograph showing the arterial cannula (A) connected to the arterial end of the cardiopulmonary circuit and (B) fixed out of the operative field.
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DISCUSSION
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This technique has been used since January 2004 in 30 neonates who underwent aortic arch reconstruction as a result of a Norwood or Sano procedure (n = 17), or aortic arch interruption or hypoplasia (n = 13). There were no hospital deaths. More recently, the technique has been applied in neonates with transposition of the great arteries undergoing an arterial switch, and for repair of truncus arteriosus and aortopulmonary window in small neonates (< 3 kg), also without any hospital deaths.
There are many advantages of this technique. Circulatory arrest is avoided due to continuous regional cerebral perfusion, and perfusion through the PTFE tubular prosthesis allows simultaneous bidirectional flow to the brain and systemic circulation. This is the major advantage over direct innominate artery cannulation where it is extremely difficult to obtain and maintain bidirectional flow to the brain and systemic circulation, particularly in very small neonates. During reconstruction of the distal aortic arch, occlusion of the aorta with a vascular clamp distal to the origin of the innominate artery allows continuous perfusion of the ascending aorta, and therefore, of the myocardium, substantially reducing the period of myocardial ischemia. The residual stump of the PTFE graft left attached to the innominate artery allows quick establishment of arterial cannulation when extracorporeal membrane oxygenation is required in the postoperative period.
Particularly in small neonates, the absence of an arterial cannula in the ascending aorta allows the execution of difficult procedures involving the ascending aorta, such as repair of truncus arteriosus and aortopulmonary window, without a cannula reducing the mobilization of the vessels and obstructing the surgical view. Of course, this technique is not necessary in these congenital heart defects, but the advantages are better mobility of the great arteries and improved surgical exposure. In small neonates with transposition of the great arteries, the arterial switch procedure is substantially facilitated by the absence of an arterial cannula in the ascending aorta. This not only affords much better mobilization of the great arteries, but allows division of the ascending aorta at a higher level than usual. The advantage is that the newly constructed aorta is shorter and consequently more posterior, hence the pulmonary artery has much more space available than with conventional arterial cannulation, and this should reduce the well-known late incidence of supravalvular pulmonary stenosis. Furthermore, after decannulation, the innominate artery remains intact, without any risk of damage. This is another advantage over direct innominate artery cannulation where there is the potential for inducing a certain degree of stenosis, particularly in very small neonates.
This technique of innominate artery cannulation through a PTFE prosthesis is safe and confers several substantial advantages over DHCA as well as direct innominate artery cannulation.
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REFERENCES
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- Newburger JW, Jonas RA, Wernovsky G, Wypij D, Hickey PR, Kuban KC, et al. A comparison of the perioperative neurologic effects of hypothermic circulatory arrest versus low-flow cardiopulmonary bypass in infant heart surgery. N Engl J Med 1993;329:1057–64.[Abstract/Free Full Text]
- Asou T, Kado H, Imoto Y, Shiokawa Y, Tominaga R, Kawachi Y, et al. Selective cerebral perfusion technique during aortic arch repair in neonates. Ann Thorac Surg 1996;61:1546–8.[Abstract/Free Full Text]
- McElhinney DB, Reddy VM, Silverman NH, Hanley FL. Modified Damus-Kaye-Stansel procedure for single ventricle, subaortic stenosis, and arch obstruction in neonates and infants: midterm results and techniques for avoiding circulatory arrest. J Thorac Cardiovasc Surg 1997;114:718–26.[Abstract/Free Full Text]
- Tchervenkov CI, Korkola SJ, Shum-Tim D, Calaritis C, Laliberte E, Reyes TU, et al. Neonatal aortic arch reconstruction avoiding circulatory arrest and direct arch vessel cannulation. Ann Thorac Surg 2001;72:1615–20.[Abstract/Free Full Text]
- Takeda Y, Asou T, Yamamoto N, Ohara K, Yoshimura H, Okamoto H. Arch reconstruction without circulatory arrest in neonates. Asian Cardiovasc Thorac Ann 2005;13:337–40.[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
