| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
LETTER TO THE EDITOR |
2nd Central Military Clinical Hospital, Department for Cardiac Surgery, 8A Bolshaya Olenya Street, Moscow, 107014, Russia
Dmitri D Savichev, MD Phone: +7 499 7854993 Fax: +7 499 7854793 Email: 7332326{at}mail.ru, 2nd Central Military Clinical Hospital, 8A Bolshaya Olenya Street, Moscow, 107014, Russia.
With the great interest we have read the excellent paper by Yamashiro et al.1 The authors describe good alternative method to widespread bilateral anterior thoracotomy through the fourth intercostal space with transverse sternotomy.2
We suppose that presented approach may be less traumatic than standard bilateral method and it could be the excellent exposure for any other manipulations on the entire thoracic aorta with any concomitant cardiac procedure. Previously the authors had reported similar aortic approach in 1 patient with intraoperative retrograde aortic dissection: initially, the thoracotomy via fourth intercostal space was performed, and after acute intraoperative retrograde aortic dissection the approach was expanded by median sternotomy3. Described aortic approach could be performed as independent maneuver in elective repair or additionally to thoracotomy in emergency situation. However, the method ensures limited access to the distal descending thoracic aorta. We suppose that rotated position of the patient somewhat hampers careful sternal closure. To facilitate sternal closure the same approach should be performed in supine position with the swab under the back and the additional exposure might be achieved by rotation of the operative table as well as during bilateral anterior thoracotomy with transverse sternotomy.
The main point of our disagreement is the described cannulation strategies for selective cerebral perfusion. We agree with the authors that femoral artery cannulation provides distal body perfusion and protection during descending thoracic aorta cross-clamping. But we have different point of view regarding the technique for selective mono- and bihemispheral cerebral perfusion. We suppose that it is unnecessary to anastomose 8-mm diameter grafts to axillary arteries because it would be more traumatic and prolongs the time of operation. It seems much easier to cannulate axillary artery by soft slender peripheral arterial cannula or cannulate right subclavian artery by specific arterial or pediatric atrial L-shaped cannula. Right subclavian artery cannulation always allows adequate perfusion of the upper part of the body during distal prosthesis-aorta anastomosis formation. Further, selective monohemispheral cerebral perfusion might be established via the same cannula in right subclavian artery by cross-clamping of the brachiocephalic trunk (if the circle of Willis is self-contained). If the bihemispheral cerebral perfusion is used, an additional circuit with two or more soft tips balloon perfusion catheters might be used during aortic arch reconstruction. The patient is placed in a head-down position and the tips are inserted directly into common carotid arteries via arch aortotomy followed by balloon catheters inflation. Insertion of balloon catheters into the aortic arch vessels is performed under short (1–1.5 minutes) upper part of the body circulatory arrest at T 20–28°C. This maneuver avoids additional incisions, graft-graft reconstruction, decreases the risk of material embolism, and simplifies the technique for cannulation. As an option, brachiocephalic trunk (right common carotid artery) and left common carotid artery could be successfully cannulated via sternotomy using 18Fr and 12Fr cannulas respectively.
The authors consider that axillary artery is always less atherosclerotic than the ascending aorta or femoral artery, moreover, each side of cannulation (ascending aorta, femoral, axillary, or subclavian artery) might be associated with risk of dissection or atheromatous debris dislocation and embolism. It is very hard to decide, what represents the greater risk: additional arterial procedure or potential risk of embolism/dissection. The extended aortic aneurysms/dissections with entire thoracic aorta involvement generally are of connective tissue disorder origin than from atherosclerosis. So should we talk about material embolism danger in such cases?
We are grateful to the authors for their interesting experience and important contribution in cardiothoracic surgery. It is one more sensible paper regarding extensive thoracic aortic replacement. We consider that it is useful option of interest for any surgeons who encounter with extensive thoracic aortic aneurysm. We congratulate the noted surgical team for innovative approach and fine results in treating such a difficult cohort of patients.
REFERENCES
Asian Cardiovasc Thorac Ann 2010;
18:92-93
© 2010 by SAGE Publications
DOI: 10.1177/0218492309353949
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
