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Eur J Cardiothorac Surg 2001;20:1240-1242
© 2001 Elsevier Science NL

How-to-do-it

Surgical strategy for repair of large pseudoaneurysms of the aortic isthmus

Marco Ricci, Eliot R. Rosenkranz, Tomas A. Salerno

Division of Cardiothoracic Surgery, University of Miami/Jackson Memorial Hospital, Miami, FL, USA

Received 23 July 2001; received in revised form 3 September 2001; accepted 4 September 2001.

Corresponding author. Great Ormond Street Hospital for Children, Cardiothoracic Unit, Great Ormond Street, London WC1N 3JH, UK. Tel.: +44-020-74059200; fax: +44-020-7813-8262
e-mail: marcoriccimd{at}hotmail.com

Abstract

Resection of unusually large pseudoaneurysms of the aortic isthmus is complex, and involves various strategies of cardiopulmonary bypass (CPB), cerebral and spinal cord protection. We report on a patient with a giant pseudoaneurysm of the distal arch and proximal descending aorta, in whom cannulation of the femoral artery was unfeasible. Instead, the right axillary artery and the left femoral vein were cannulated. This technique allowed to perform a left anterolateral thoracotomy with the patient already on CPB and hypothermic, and to shorten the duration of hypothermic circulatory arrest.

Key Words: Descending thoracic aortic aneurysm, aortic isthmus, hypothermic circulatory arrest, cerebral protection, axillary artery

1. Introduction

The management of unusually large pseudoaneurysms of the aortic asthmus is complex. Aside from the technique of aortic replacement, other factors, such as surgical approach and strategy of myocardial, cerebral, and spinal cord protection, are of critical importance.

The standard approach to aneurysmal disease of the proximal descending thoracic aorta is through a left thoracotomy [1]. However, entering the chest in the presence of unusually voluminous pseudoaneurysms may be hazardous. The complexity of the operation is even greater in reoperations for pseudoaneurysms. In these situations, it has been common practice to use cardiopulmonary bypass (CPB) and cooling, usually via femoral-femoral cannulation, prior to entering the chest, and then proceed with hypothermic circulatory arrest (HCA) [1,2].

However, when femoral cannulation is used, a remote risk of cerebral embolization exists. Also, this technique may not be applicable to patients in whom the femoral arteries are small, or diseased. The aim of this brief article is to describe a technique that can be used in these complex situations.

2. Technique

Our experience consists of one patient who underwent resection of coarctation of the aorta at age 12. The aorta was replaced with a Dacron graft. The patient was asymptomatic for years, until he developed left-sided chest discomfort. There was no pressure gradient between upper and lower extremities. A chest CT (Fig. 1A) showed a large pseudoaneurysm of the aortic isthmus, as did magnetic resonance angiography (MRA) (Fig. 1B).



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  		Fig. 1. (A) Computed tomography (CT) angiogram of the chest showing the large pseudoaneurysm involving the proximal descending thoracic aorta. (B) Contrast-enhanced magnetic resonance (MR), delineating the vascular anatomy of the arch and descending thoracic aorta.

 
At surgery, atrial cannulation was performed through the femoral route. As the left femoral artery was small, arterial cannulation was accomplished by exposing the right axillary artery through a subclavicular incision. An 8 mm Dacron graft was connected end-to-side to the artery using 6-0 prolene. The arterial cannula was then inserted into the graft (Fig. 2A) . While maintaining a sterile field, the patient was turned into a 45° right decubitus position. CPB was instituted, and cooling was begun. At 20°C, a left anterolateral thoracotomy on the third intercostal space was made. The large pseudoaneurysm was separated from the chest wall. Due to its remarkable size, proximal extent, and to the presence of extensive adhesions, cross-clamping of the aorta was unfeasible. At 16°C, HCA was established. The pseudoaneurysm involved the aorta proximal to the Dacron graft previously inserted (Fig. 2B). The repair was accomplished by using a 23 mm Dacron graft, which was at first anastomosed to the distal arch (Fig. 2B). The graft was then clamped, and low flow, hypothermic CPB was resumed (Fig. 2C). The new graft was connected distally to the old one, while spinal protection was provided by deep hypothermia [4]. The graft was unclamped (Fig. 2D). As rewarming was progressing, the left subclavian artery was reimplanted on the graft. The patient was then separated from CPB, the thoracotomy was closed, and the patient was placed again supine for decannulation.



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  		Fig. 2. (A) The operation is initiated by central venous cannulation through the left femoral vein, and arterial cannulation of the right axillary artery through an 8 mm Dacron graft. (B) Under hypothermic circulatory arrest (HCA), the pseudoaneurysm is opened and the proximal anastomosis is constructed. Of note, the area of aneurysmal dilatation involved the segment of native aorta just proximal to the tube graft used to repair the coarctation (small arrow). (C) After the proximal anastomosis is completed, the graft is clamped. Low-flow hypothermic CPB is resumed so as to immediately restore flow to the ascending aorta and arch. The distal anastomosis is then constructed, while spinal cord protection is provided by profound hypothermia. (D) Once aortic continuity is reestablished, the whole body is reperfused and the patient is rewarmed.

 
3. Discussion

The use of the right axillary artery as the inflow for CPB has been described for operations on the ascending aorta and arch [3]. In contrast, in our case this technique was utilized to approach a large pseudoaneurysm of the aortic isthmus.

Although other strategies could have been used, cannulation of the right axillary artery presented several advantages. It allowed to proceed with thoracotomy under controlled conditions, and it lead to immediate cerebral reperfusion after the proximal anastomosis was completed. A potential shortcoming was that cannulation of the right axillary artery had to be undertaken with the patient supine, whereas a lateral decubitus position was required for thoracotomy. This problem, however, was overcome by turning the patient to a 45° lateral decubitus, which allowed to maintain sterility and obtain adequate exposure of the pseudoaneurysm. In contrast to direct cannulation, we favored graft interposition mainly to reduce the risk of kinking of the arterial line.

In light of this, one could argue that other approaches could have been used. A median sternotomy would have allowed ideal conditions for cannulation, also offering the adjunct of retrograde cerebral perfusion, but it would have unlikely provided sufficient exposure of the pseudoaneurysm. A transverse thoraco-sternotomy also would not have been free from disadvantages, including the magnitude of the approach and the necessity for entering the chest in an uncontrolled situation, with the patient neither cannulated nor on CPB. Lastly, cannulation of the left axillary artery, while obviating the need for turning the patient twice, would have prolonged HCA during reconstruction of the left subclavian artery.

Although a single case may not be sufficient to draw definitive conclusions, in these complex situations the use of the right axillary artery may be a resourceful alternative.

References

  1. Coselli J.S., Plestis K.A., La Francesca S., Cohen S. Results of contemporary surgical treatment of descending thoracic aortic aneurysms: experience in 198 patients. Ann Vasc Surg 1996;10(2):131-137.[Medline]
  2. Crawford E.S., Coselli J.S., Safi H.J. Partial Cardiopulmonary bypass, hypothermic circulatory arrest, and posterolateral exposure for thoracic aortic aneurysm operation. J Thorac Cardiovasc Surg 1987;94(6):824-827.[Abstract]
  3. Sabik J.F., Lytle B.W., McCarthy P.M., Cosgrove D. Axillary artery: an alternative site of arterial cannulation for patients with extensive aortic and peripheral vascular disease. J Thorac Cardiovasc Surg 1995;109:885-891.[Abstract]
  4. Laschinger J.C., Izumoto H., Kouchoukos N.T. Evolving concepts in prevention of spinal cord injury during operations on the descending thoracic and thoracoabdominal aorta. Ann Thorac Surg 1987;44:667-674.[Abstract]



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