Management of Cardiac Arrest During Explant of Infected TEVAR on Femoro-Femoral Bypass. Use of Dual Arterial Cannulation Cardiopulmonary Bypass and Deep Hypothermia Circulatory Arrest.

P0206 

Abstract Submission 

Salim Aziz (1), Jenna Aziz (2), Bao Nguyen (3), Shawn Sarin MD (3)

(1) George Washington University Hospital, United States, (2) Ohio State Wexner Medical Center, Columbus, OH, (3) George Washington University Hospital, Washington, DC

Salim Aziz    -  Contact Me
George Washington University Hospital

Jenna Aziz    -  Contact Me
Ohio State Wexner Medical Center

Bao-Ngoc Nguyen    -  Contact Me
George Washington University Hospital

Shawn Sarin MD    -  Contact Me
George Washington University Hospital

Salim Aziz    -  Contact Me
N/A

Objective:
The management of cardiac arrest whilst on femoro-femoral cardiopulmonary bypass (FF-CPB) during removal of an infected TEVAR can be challenging. We present our approach to this conundrum: change to dual site arterial cannulation CPB and use of deep hypothermia circulatory arrest (DHCA).

Methods:
A 66-year-old female four months previously presented with severe chest pain. CTA showed a large descending thoracic (DTA) aneurysm (6.4cm) and large penetrating ulcers. She had a history of chest pain, smoking, severe hypertension and a coronary stent. She underwent TEVAR placement. She now re-presented with hypertension and severe low back pain. A CTA was done and an endoleak was seen at the distal end of the TEVAR. A "relining" of the prior TEVAR was performed at an outside hospital. Twelve hours after discharge she was readmitted to an ER because of severe chest pains. A repeat CTA (Fig 1) showed extensive air around the TEVAR with a WBC of 25k. A diagnosis of an infected TEVAR (gram negative rods on blood culture) was made and she was transferred to our hospital. Her EF was approximately 40%. There was no esophageal leak on a swallow study. Plan: Urgent removal of infected TEVAR on femoro-femoral bypass (FF-CPB).

Operation: The thoraco-abdominal (TAA incision) and fem/fem access for CPB were done concurrently. On opening the chest there was extensive pus in the chest and she decompensated rapidly with global cardiac hypokinesis/distension, hypotension, arrhythmias requiring cardiac massage which persisted despite placement on FF-CPB. Action: A second arterial cannula was placed in the arch and Yed to the femoral cannula and the heart vented through the left superior pulmonary vein. Her hemodynamics and arrhythmias rapidly stabilized. The distal arch and DTA were densely adherent, and the aortic clamp could not be placed across the distal arch. The patient was rapidly cooled to 180C. Under DHCA, the infected TEVARs were removed, and a Rifampicin soaked 28 mm Hemashield graft interposed to above the celiac artery. Once the proximal anastomosis was completed a clamp was placed on the graft and patient rewarmed. Because of persistent LV dysfunction on weaning off CPB, she was transitioned to peripheral VAECMO (extracorporeal membrane oxygenation). The patients had severe coagulopathy requiring use of thoraco-abdominal wound vac and blood products. Her post-op course was complicated with poor wound healing requiring a wound vac, respiratory (ventilator) and renal support (dialysis). She was transferred to long-term care.

Summary:
Rapid conversion to dual site (central and peripheral) arterial cannulation with LV venting should be used for cardiac arrest on fem-fem CPB for TEVAR removal not responsive to standard measures. If the aorta cannot be cross-clamped DHCA can be used.

Descending/Thoracoabdominal Aorta