A Technique for Safe Redo Sternotomy in Patients with Aortic Proximity to the Sternum

2021 ◽  
Vol 13 (1) ◽  
pp. 89-91
Author(s):  
Constantine D. Mavroudis ◽  
Benjamin Smood ◽  
Madison A. Grasty ◽  
Stephanie Fuller ◽  
Nimesh D. Desai
Keyword(s):  
Axillary Artery ◽  
Femoral Vein ◽  
Innominate Artery ◽  
Aortic Injury ◽  
Low Flow ◽  
Close Proximity ◽  
Increase Risk ◽  
The Right ◽  
Selective Antegrade Cerebral Perfusion ◽  
Antegrade Cerebral Perfusion

The risk of redo sternotomy is greatly elevated in the setting of aortic proximity to the sternum. Current strategies to avoid catastrophic neurologic injury upon sternal reentry include establishment of peripheral bypass with the use of deep hypothermia and low-flow bypass, both of which may increase risk of neurologic complications. Here, we describe a technique for safe sternal reentry and illustrate its successful use in a patient with close proximity of the aorta to the sternum. With this technique, peripheral cardiopulmonary bypass is established prior to sternal reentry via cannulation of the right axillary artery and femoral vein, and the patient is cooled as the innominate artery is dissected, mobilized, and controlled. This permits the rapid institution of selective antegrade cerebral perfusion (SACP) in the event of aortic injury during sternal reentry. Once the innominate artery is isolated and SACP is initiated, one can safely complete the redo sternotomy, dissection, and distal ascending aortic cross-clamping to continue the operation without interruption in cerebral blood flow. This technique offers a safe approach in select patients and should be utilized in similar high-risk cases.

Cerebral Protection Using Percutaneous Normothermic Bilateral Antegrade Cerebral Perfusion During Total Arch TEVAR in a Patient With Shaggy Aorta

2020 ◽  
Vol 27 (3) ◽  
pp. 405-413 ◽  
Author(s):  
George Joseph ◽  
Rahul Pillai ◽  
Vinayak Shukla ◽  
Krothapalli S. Babu ◽  
Shankar Manickam ◽  
...  
Keyword(s):  
Cerebral Perfusion ◽  
Inferior Vena ◽  
Axillary Artery ◽  
Vena Cava ◽  
Innominate Artery ◽  
Complete Separation ◽  
Balloon Occlusion ◽  
Shaggy Aorta ◽  
The Right ◽  
Antegrade Cerebral Perfusion

Purpose: To report a technique of global cerebral embolic protection (CEP) designed for use during thoracic endovascular aortic repair (TEVAR). Technique: Arterial cannulas are inserted percutaneously in the right axillary artery (12-F) and left common carotid artery (LCCA; 10-F) to provide normothermic antegrade cerebral perfusion during TEVAR with neuromonitoring. Inferior vena cava blood is drawn using a 19-F femoral cannula, filtered, oxygenated, and delivered through independent roller pumps to the arterial cannulas. Static CEP is obtained by balloon occlusion of the 3 aortic arch branches proximally, resulting in complete separation of aortic and cerebral blood flow; static CEP is used during aortic endograft delivery and deployment. Dynamic CEP, obtained by creating flow reversal in the innominate artery and proximal LCCA, is used at all other times. Successful use of this CEP technique is illustrated in a patient with shaggy aorta undergoing fenestrated total arch TEVAR. Conclusion: Percutaneous normothermic bilateral antegrade cerebral perfusion provides effective CEP during TEVAR.

Unilateral Antegrade Cerebral Perfusion Through the Right Axillary Artery Provides Uniform Flow Distribution to Both Hemispheres of the Brain

Circulation ◽  
1999 ◽  
Vol 100 (suppl_2) ◽  
Author(s):  
Jian Ye ◽  
Guangping Dai ◽  
Lawrence N. Ryner ◽  
Piotr Kozlowski ◽  
Luojia Yang ◽  
...  
Keyword(s):  
Cerebral Blood Volume ◽  
Axillary Artery ◽  
Circulatory Arrest ◽  
Flow Distribution ◽  
Mr Perfusion ◽  
Mr Perfusion Imaging ◽  
Regional Cerebral Blood Volume ◽  
The Right ◽  
The Brain ◽  
Antegrade Cerebral Perfusion

Background —Bilateral antegrade cerebral perfusion (ACP) has decreased in popularity over the past decade because of its complexity and the risk of cerebral embolism. We used magnetic resonance (MR) perfusion imaging to assess flow distribution in both hemispheres of the brain during unilateral ACP through the right carotid artery via a cannula placed in the right axillary artery in conjunction with hypothermic circulatory arrest. Methods and Results —Twelve pigs were randomly exposed to 120 minutes of either bilateral ACP through both carotid arteries (n=6) or unilateral ACP through the right axillary artery (n=6) at pressures of 60 to 65 mm Hg at 15°C, followed by 60 minutes of cardiopulmonary bypass at 37°C. MR perfusion images were acquired every 30 minutes before, during, and after ACP. The brain was perfusion fixed for histopathology. During initial normothermic cardiopulmonary bypass, MR perfusion imaging showed a uniform distribution of flow in the brain. In both the bilateral and unilateral ACP groups, the same pattern was maintained, with an increase in regional cerebral blood volume during ACP and reperfusion. The changes in regional cerebral blood volume and mean transit time were similar in both hemispheres during and after unilateral ACP. No difference was observed between the 2 groups. Histopathology showed normal morphology in all regions of the brain in both groups. Conclusions —Both bilateral ACP and unilateral ACP provide uniform blood distribution to both hemispheres of the brain and preserve normal morphology of the neurons after prolonged hypothermic circulatory arrest.

scholarly journals Percutaneous or Side-Arm Graft Right Subclavian Artery Cannulation via Median Sternotomy

Aorta ◽  
2019 ◽  
Vol 07 (05) ◽  
pp. 150-153
Author(s):  
Corrado Cavozza ◽  
Antonio Campanella ◽  
Pellegrino Pasquale ◽  
Andrea Audo
Keyword(s):  
Cardiopulmonary Bypass ◽  
Subclavian Artery ◽  
Circulatory Arrest ◽  
Median Sternotomy ◽  
Innominate Artery ◽  
Bypass Flow ◽  
Surgical Incision ◽  
Artery Cannulation ◽  
The Right ◽  
Antegrade Cerebral Perfusion

AbstractSeveral cannulation sites alternative to the ascending aorta, such as femoral, right axillary, carotid, innominate artery, and, less commonly, apical sites, have been proposed. Cannulation of the right subclavian artery, through sternotomy, is one possible means of establishing cardiopulmonary bypass, hence avoiding a second surgical incision. In our experience, cardiopulmonary bypass flow was adequate and circulatory arrest with antegrade cerebral perfusion was successfully performed in all cases. There was no in-hospital mortality.

scholarly journals The use of innominate artery cannulation for antegrade cerebral perfusion in aortic dissection

2020 ◽  
Vol 15 (1) ◽  
Author(s):  
Eden C. Payabyab ◽  
Jonathan M. Hemli ◽  
Allan Mattia ◽  
Alex Kremers ◽  
Sohrab K. Vatsia ◽  
...  
Keyword(s):  
Aortic Dissection ◽  
Aortic Root ◽  
Cerebral Perfusion ◽  
Innominate Artery ◽  
Type A ◽  
Ascending Aorta ◽  
Aortic Root Replacement ◽  
Artery Cannulation ◽  
Selective Antegrade Cerebral Perfusion ◽  
Antegrade Cerebral Perfusion

Abstract Background Direct cannulation of the innominate artery for selective antegrade cerebral perfusion has been shown to be safe in elective proximal aortic reconstructions. We sought to evaluate the safety of this technique in acute aortic dissection. Methods A multi-institutional retrospective review was undertaken of patients who underwent proximal aortic reconstruction for Stanford type A dissection between 2006 and 2016. Those patients who had direct innominate artery cannulation for selective antegrade cerebral perfusion were selected for analysis. Results Seventy-five patients underwent innominate artery cannulation for ACP for Stanford Type A Dissections. Isolated replacement of the ascending aorta was performed in 36 patients (48.0%), concomitant aortic root replacement was required in 35 patients (46.7%), of whom 7 had a valve-sparing aortic root replacement, ascending aorta and arch replacement was required in 4 patients (5%). Other procedures included frozen elephant trunk (n = 11 (14.7%)), coronary artery bypass grafting (n = 20 (26.7%)), and peripheral arterial bypass (n = 4 (5.3%)). Mean hypothermic circulatory arrest time was 19 ± 13 min. Thirty-day mortality was 14.7% (n = 11). Perioperative stroke occurred in 7 patients (9.3%). Conclusions This study is the first comprehensive review of direct innominate artery cannulation through median sternotomy for selective antegrade cerebral perfusion in aortic dissection. Our experience suggests that this strategy is a safe and effective technique compared to other reported methods of cannulation and cerebral protection for delivering selective antegrade cerebral perfusion in these cases.

scholarly journals Fatal intraoperative dissection of the innominate artery due to perfusion through the right axillary artery

2000 ◽  
Vol 120 (2) ◽  
pp. 405-406 ◽  
Author(s):  
Kazuhito Imanaka ◽  
Shunei Kyo ◽  
Hiroaki Tanabe ◽  
Hiroshi Ohuchi ◽  
Haruhiko Asano ◽  
...  
Keyword(s):  
Axillary Artery ◽  
Innominate Artery ◽  
The Right

scholarly journals The Use of Innominate Artery Cannulation for Antegrade Cerebral Perfusion in Aortic Dissection

2020 ◽  
Author(s):  
Eden C Payabyab ◽  
Jonathan M. Hemli ◽  
Allan Mattia ◽  
Alex Kremers ◽  
Sohrab K. Vatsia ◽  
...  
Keyword(s):  
Aortic Dissection ◽  
Aortic Root ◽  
Cerebral Perfusion ◽  
Innominate Artery ◽  
Type A ◽  
Ascending Aorta ◽  
Aortic Root Replacement ◽  
Artery Cannulation ◽  
Selective Antegrade Cerebral Perfusion ◽  
Antegrade Cerebral Perfusion

Abstract Background: Direct cannulation of the innominate artery for selective antegrade cerebral perfusion has been shown to be safe in elective proximal aortic reconstructions. We sought to evaluate the safety of this technique in acute aortic dissection. Methods: A multi-institutional retrospective review was undertaken of patients who underwent proximal aortic reconstruction for Stanford type A dissection between 2006 and 2016. Those patients who had direct innominate artery cannulation for selective antegrade cerebral perfusion were selected for analysis. Results: Seventy-five patients underwent innominate artery cannulation for ACP for Stanford Type A Dissections. Isolated replacement of the ascending aorta was performed in 36 patients (48.0%), concomitant aortic root replacement was required in 35 patients (46.7%), of whom 7 had a valve-sparing aortic root replacement, ascending aorta and arch replacement was required in 4 patients (5%). Other procedures included frozen elephant trunk (n = 11 (14.7%)), coronary artery bypass grafting (n = 20 (26.7%)), and peripheral arterial bypass (n = 4 (5.3%)). Mean hypothermic circulatory arrest time was 19 ± 13 minutes. Thirty-day mortality was 14.7% (n = 11). Perioperative stroke occurred in 7 patients (9.3%).Conclusions: This study is the first comprehensive review of direct innominate artery cannulation through median sternotomy for selective antegrade cerebral perfusion in aortic dissection. Our experience suggests that this strategy is a safe and effective technique compared to other reported methods of cannulation and cerebral protection for delivering selective antegrade cerebral perfusion in these cases.

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