Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 8  |  Issue : 3  |  Page : 250-252

Differential hypothermic arrest with double-arterial cannulation


Department of Cardio Vascular and Thoracic Surgery, U. N. Mehta Institute of Cardiology and Research Centre (Affiliated to B. J. Medical College), New Civil Hospital Campus, Ahmedabad, Gujarat, India

Date of Submission08-Jul-2020
Date of Decision14-Jul-2020
Date of Acceptance15-Aug-2020
Date of Web Publication6-Jul-2021

Correspondence Address:
Jignesh Kothari
Department of Cardio Vascular and Thoracic Surgery, U. N. Mehta Institute of Cardiology and Research Centre (Affiliated to B. J. Medical College), New Civil Hospital Campus, Ahmedabad, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_94_20

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  Abstract 


Thoracic aortic aneurysm (TAA) is a dilation of the aorta of >150% of its normal diameter for a given segment. Weakening of aortic walls results in saccular, fusiform, or diffuse dilation. The incidence of TAA is about 10 for every 100,000 adults, with 20% being of familial origin. TAA carries a high risk of morbidity and mortality, with surgery and thoracic endovascular aortic repair being the definitive treatment. In this case report, we present an innovative approach for addressing concomitant coronary artery disease and TAA repair using double-arterial cannulation and differential hypothermic circulatory arrest without any postoperative neurological sequelae.

Keywords: Ischemic heart disease, thoracic aortic aneurysm, thoracic endovascular aortic repair


How to cite this article:
Sharma R, Kothari J, Baria K, Patel A, Desai D. Differential hypothermic arrest with double-arterial cannulation. Indian J Vasc Endovasc Surg 2021;8:250-2

How to cite this URL:
Sharma R, Kothari J, Baria K, Patel A, Desai D. Differential hypothermic arrest with double-arterial cannulation. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2021 Jul 25];8:250-2. Available from: https://www.indjvascsurg.org/text.asp?2021/8/3/250/320630




  Introduction Top


Thoracic aortic aneurysm (TAA) is a dilation of the aorta of >150% of its normal diameter for a given segment.[1] Weakening of aortic walls results in saccular, fusiform, or diffuse dilation. The incidence of TAA is about 10 for every 100,000 adults, with 20% being of familial origin.[2] TAA carries a high risk of morbidity and mortality, with surgery and thoracic endovascular aortic repair being the definitive treatment.

In this report, we present a case of a 51-year-old male with ischemic heart disease and TAA for coronary artery bypass graft and aneurysm repair through midline sternotomy. We describe an innovative technique with double-arterial cannulation and differential deep hypothermic circulatory arrest.


  Case Report Top


A 51-year-old male, known smoker with a history of hypertension for 4 years, presented to the cardiac clinic with a history of back pain for 1 week. The electrocardiogram and cardiac enzymes were diagnostic of acute coronary syndrome. Angiogram and computed tomography (CT)-angio confirmed a saccular aneurysm of 52 mm × 44 mm at vertebral level D6–D9 with triple-vessel disease [Figure 1].
Figure 1: Preoperative computed tomography-angio showing descending thoracic aneurysm

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The surgical treatment involved coronary artery bypass (left internal mammary artery-left anterior descending artery [LIMA-LAD], saphenous vein grafts-obtuse marginal artery [SVG-OM], and posterior descending artery [PDA]) with TAA repair under general anesthesia. After midline sternotomy, Wye cannulation of ascending aorta and right femoral artery was done along with bicaval cannulation for venous return. The patient was put on cardiopulmonary bypass (CPB); distal anastomosis of OM and PDA was done on the empty beating heart. Aneurysm was identified, and distal control of the diseased aorta was taken. Proximal control was difficult due to its proximity to the left inferior pulmonary vein and the presence of dense pleural adhesions. Chitwood clamp was used for clamping the aorta proximal to the aneurysm, and Cooley aortic clamp was used for distal clamping. The aneurysm was opened and clots were removed. However, the proximal clamp was partial, leading to flooding of the surgical field. To create a bloodless field, a differential deep hypothermic circulatory arrest was done by leaving the descending aorta clamp in situ and releasing the femoral clamp to maintain perfusion to the lower half of the body through CPB. The temperature was maintained at 21°C during the differential hypothermic arrest.

TAA repair was done with Dacron interposition graft [Figure 2]. Reperfusion was started for the upper half of the body after de-airing and rewarming was done. Distal anastomosis of LIMA-LAD was done, followed by proximal anastomosis of SVG for OM and PDA done. Rest of the surgery went uneventful. The total CPB time was 193 min, and differential deep hypothermic arrest time was 11 min. The total operative time was around 4 h and 30 min. The patient was shifted to the postoperative unit and extubated on the 2nd postoperative day. The patient was able to ambulate well and had no cognitive issues or neurological deficit. Postoperative CT scan showed no leak and good alignment of the graft [Figure 3].
Figure 2: Descending thoracic aneurysm interposition graft

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Figure 3: Postoperative computed tomography-angio showing interposition graft in situ

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  Discussion Top


TAA surgery is considered an especially high-risk surgery with a considerable risk of bleeding.[3] Complex aortic reconstruction, urgent presentations, prolonged CPB, and hypothermia account for the higher risk of bleeding, neurological issues, and paraplegia.[4] A novel technique to deal with the issue of blood loss and counter the side effects of prolonged CPB and hypothermia is double-arterial cannulation. The strategy is well documented and cited in literature.[5] It involves clamping the aorta both proximally and distally to the dilatation, thereby isolating the diseased area and providing a good control and better spinal and brain protection as adequate perfusion is maintained throughout. Another method to create a bloodless field is by total circulatory arrest. In our case, we used a combination of the two techniques.

An inadequate proximal control of the aneurysm caused difficulty in creating good surgical conditions. Because the patient was already on cardiopulmonary bypass and the circulation of upper and lower half of the body had been isolated with double cannulation, the proximal half was put on total circulatory arrest with deep hypothermia. This differential total circulatory arrest along with dual aortic cannulation allowed for a safe period of surgery without the risk of neurological injury. Isolation of circulation of the upper and lower half of the body provides better spine and brain protection. The duration of surgery can be prolonged without the risk of the rising lactate levels as the maintained circulation allows for washout. Dual cannulation of the aorta significantly decreases the blood loss and reduces the requirement of blood transfusion. A good bloodless field allows for more flexibility for the surgeon to maneuver around the aneurysm and get better outcomes.

This novel technique may provide for alternatives to total deep hypothermic arrest and provide better spinal cord and brain protection, thereby reducing the incidence of paraplegia and neurocognitive dysfunction.

Thoracic endovascular aortic repair is one of the definitive treatments of TAA. Although thoracic endovascular aortic repair is less invasive and has lower perioperative mortality, the long-term survival benefits are greater with open repairs. The relatively young age of the patient, low surgical risk, and coexisting coronary artery disease tip the balance in favor of open surgery in our case. Moreover, combined surgery reduces the hospital days and loss of working hours as well as is cost-effective for both the patient and our setup.


  Conclusion Top


Double-aortic cannulation offers a significant advantage with reduced blood loss and better operative conditions. Use of differential deep hypothermic circulatory arrest may offer better spinal cord, brain, and vital organ perfusion. Further studies are required to corroborate these findings.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

This study was financially supported by U.N. Mehta Institute of Cardiology and Research Centre.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE Jr., et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation 2010;121:266-369.  Back to cited text no. 1
    
2.
Clouse WD, Hallett JW Jr., Schaff HV, Gayari MM, Ilstrup DM, Melton LJ 3rd. Improved prognosis of thoracic aortic aneurysms: A population-based study. JAMA 1998;280:1926-9.  Back to cited text no. 2
    
3.
Despotis G, Avidan M, Eby C. Prediction and management of bleeding in cardiac surgery. J Thromb Haemost 2009;7 Suppl 1:111-7.  Back to cited text no. 3
    
4.
Williams JB, Phillips-Bute B, Bhattacharya SD, Shah AA, Andersen ND, Altintas B, et al. Predictors of massive transfusion with thoracic aortic procedures involving deep hypothermic circulatory arrest. J Thorac Cardiovasc Surg 2011;141:1283-8.  Back to cited text no. 4
    
5.
Duru S, Erdem M, Agca E, Kaplan T, Ardic S. Thoracic aortic aneurysm: A rare case report. Turkish Thoracic 2013;14:78-80.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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