Dual inflow without circulatory arrest for hemiarch replacement
Open distal graft to proximal aortic arch anastomosis is central to a hemiarch replacement. Even if the ischemic tolerance time of several organs during circulatory arrest (CA) at normothermia is much longer than that of the brain, very little is known about the safety and clinical efficacy of moderate hypothermia for organ protection during the average duration of CA needed for aortic arch replacement. Hemiarch replacement using the standard techniques of deep hypothermia and antegrade perfusion has often ignored the effects of prolonged distal body CA. Maintenance of distal organ, especially the liver and kidney, perfusion reduces the risk of postoperative renal dysfunction and coagulopathy.
A 72-year-old female patient was referred to our institute due to chest discomfort. Radiologic investigations revealed a giant aneurysm of the ascending aorta extending but confined to the proximal aortic arch. We performed an alternative technique for hemiarch replacement using a dual inflow source.
Although this technique cannot apply to all aneurysmal aortic diseases, our basic technique involving the use of dual inflow may be well suited for standard hemiarch replacement that is confined to the proximal aortic arch, given the shortening of the bypass and ischemic times.
KeywordsDual inflow Hemiarch replacement No circulatory arrest
Circulatory arrest abbreviations
Selective antegrade cerebral perfusion
Although the use of selective antegrade cerebral perfusion (SACP) during circulatory arrest (CA) has allowed aortic arch repair to be performed safely with moderate hypothermic CA , the susceptibility of the distal organ to ischemia often has been ignored during CA . In particular, visceral organ injury cannot be guaranteed during moderate hypothermic CA when cerebral perfusion is used alone. We present an alternative technique for hemiarch replacement using a dual inflow strategy that does not require deep hypothermic CA.
Discussion and conclusions
Open distal graft to proximal aortic arch anastomosis is the sine qua non of hemiarch aortic replacement. Many institutions have moved to a strategy of mild to moderate hypothermia with SACP for aortic arch replacement [1, 3]. Even if several organs, such as the liver, the kidney or even the spinal cord, have a much longer ischemic tolerance time at normothermia during CA than the brain, very little is known about the safety and clinical efficacy of mild-to-moderate hypothermia for organ protection during the average CA time needed for aortic arch replacement. Even short periods of cerebral CA and arch branch manipulation have been shown to be deleterious for higher mental function and to create an opportunity for cerebral embolization of air and debris [1, 2]. Using unilateral cerebral perfusion, often via the right axillary artery, while seeming to avert cerebral CA, still poses issues related to contralateral hemispheric hypoperfusion or ipsilateral hyperperfusion . Perioperative hepatic and renal dysfunction substantially contribute to postoperative morbidity and mortality . Arch replacement using standard techniques of deep hypothermia and antegrade perfusion often ignore the effects of prolonged distal body CA. Maintenance of distal organ and especially liver and kidney perfusion reduces the risk of postoperative renal dysfunction and coagulopathy . Thus, our proposed technique can avoid many of the shortcomings of standard arch replacement strategies. A dual inflow source is important not only for providing distal body perfusion during arch branch reconstruction but also for lowering perfusion pressure gradients, thereby avoiding problems such as hyperperfusion of the right hemisphere that arise when right axillary cannulation is used alone . The bypass time for the patient was 60 min.
Our proposed technique can be applied safely, but there are some cautions. Care must be taken to avoid exposure to the recurrent laryngeal nerve during arch vessel dissection or clamping the mid-arch, as the technique requires adequate and precise exposure of the aortic arch.
Although this technique cannot apply to all aneurysmal aortic diseases, our basic technique using dual inflow may be well suited for standard hemiarch replacement cases in which the aneurysm is confined to the proximal aortic arch, given the shortening of the bypass and ischemic times.
Funding from Research Institute of Clinical Medicine of Chonbuk National University and Biomedical Research Institute of Chonbuk National University Hospital is gratefully acknowledged.
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KHK is the corresponding author. KHK conceived of the study and participated in its design and coordination. TYK and KHK both contributed to drafting the manuscript. Both authors have read and approved the final manuscript.
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Consent for publication of this case report in its entirety was obtained from the patient.
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- 2.Stephen Spindel, Bobby Yanagawa, Javier Mejia, et al. Intermittent upper and lower body perfusion during circulatory arrest is safe for aortic repair. Perfusion, 2018 Sep 5: doi: https://doi.org/10.1177/0267659118798178.
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