Aortic arch replacement for infectious aortitis without circulatory arrest

P0042 

Case Video Submission 

Eduard Quintana (1), Elena Sandoval (2), Robert Pruna-Guillen (2), Maria Ascaso Arbona (2)

(1) Hospital Clínic Barcelona Cardiovascular Surgery Department. University of Barcelona, Barcelona, Barcelona, (2) Hospital Clínic Barcelona Cardiovascular Surgery Department, Barcelona, Barcelona

Eduard Quintana    -  Contact Me
Hospital Clínic Barcelona Cardiovascular Surgery Department. University of Barcelona

Elena Sandoval    -  Contact Me
Hospital Clínic Barcelona Cardiovascular Surgery Department

Robert Pruna-Guillen    -  Contact Me
Hospital Clínic Barcelona Cardiovascular Surgery Department

Maria Ascaso    -  Contact Me
Hospital Clínic Barcelona Cardiovascular Surgery Department

Eduard Quintana    -  Contact Me
Hospital Clínic Barcelona Cardiovascular Surgery Department

• Objective:
Conventional approach to aortic arch surgery requires hypothermic cardiopulmonary bypass (CPB) and lower body circulatory arrest. Prolonged CPB and lower body ischemia have negative impact on outcomes in patients with visceral abnormalities and ongoing infection.Arch replacement under uninterrupted perfusion can minimize organic injury. The objective of this submission is to demonstrate the feasibility of open aortic arch replacement without circulatory arrest in specific patient conditions with appropriate anatomy.

• Case Video Summary:
Open arch repair with a distal anastomosis performed in zone 2 under mild hypothermia (34-35ºC) and uninterrupted perfusion. The patient is cannulated in the right axillary artery and right femoral artery. Under full CPB fow the aortic balloon in the descending aorta (inserted through the left femoral artery) is inflated, the proximal brachiocephalic trunk is clamped and the left carotid artery snared. The aorta is opened and retrograde cold blood cardioplegia administered while maintain unilateral cerebral perfusion (right axillary) and distal body perfusion (right femoral artery). A cerebral perfusion cannula is inserted in the left carotid artery while the left subclavian is back bleeding is blocked with a Foley catheter. Distal anastomosis is performed with a polyester graft and 4/0 monofilament in zone 2. The graft is deaired and occluded reestablishing left subclavian artery perfusion. The proximal anastomosis is performed and the heart reperfused. The operation continues with separate head vessel reconstruction (brachiocephalic trunk and left carotid artery) with a bifurcated polyester graft. CPB time 177 min Cardiac ischemic time were 62 min. The patient was extubated within the first 24 h and discharged without complications. After 9 months there is no evidence of relapse and the patient has no physical restriction.

• Conclusions:
Aortic arch replacement avoiding moderate/deep hypothermia and circulatory arrest is
feasible, provided that there is no precluding thoracoabdominal aorta or peripheral disease. It provides a bloodless and comfortable aortic arch operative [eld, ensuring thorough and unrushed tissue debridement. There is potential to minimize coagulopathy and end organ damage. The downsides of this approach are the need for additional femoral artery manipulation and endoclamping of the descending aorta. Similar anatomies could be safely tackled under normothermic CPB.

Aortic Arch