[HSF] Aortic purse strings in thin large aortas.

[prasannasimha]

I use 3/0 for adults and 4/0 or 5/0 in children depending on the size (2 
purse strings) I put a third Z stitch after cannula removal. I haven't 
had any real major problems with this. I do use a pericardial/Teflon 
pledget  on my third Z stitch if there is bleeding.
One important thing is that if there is bleeding it is important to cut 
open the surrounding adventitia to prevent a "blue bleb" dissection. The 
subsequent bites can imbricate this lifted adventitial along with a 
pledget as something like a reverse Floten flap.
I do disagree with the pledget causing bleeding underneath concept. I 
have had some of my teachers say this and was not using pledgets but 
later realized they were wrong. Precisely placed pledgetted sutures can 
be a god send . They also minimize cutting through if the aorta is thin.
One little trick is to make a longer strip of pericardium (roughly more 
than double the regular pledget. Use one end as a pledget and take the 
needles through the tissue and then pass the needles into the remaining 
part of the pericardium. This folds up the pericardium and acts as a 
local patch which works very well. I hope this description can be 
translated into the mind's eye. This has worked many a time when there 
has been bleeding.
Caveats to managing this are to reduce the pressure - head up and SNP 
usually works and it is good to get the pressures below 90 and better 
still in the 60's.But if the dP/dT is really high based on the 
vigorousness of cardiac contractions temporary rapid ventricular pacing 
at 180 -200 beats or a short period of fibrillation - defibrillation may 
be used conveniently.
If it still persist there is tension on the aorta and then you must 
consider patching it - either with a large piece of pericardium over the 
whole area or femoral bypass with open patching - something which all of 
us should pray we needn't have to do.
The best thing even in thin aortae is to avoid piercing through and 
through when taking a purse string. Care taken initially goes a really 
long way.
A Marfan aorta must be pledgetted. It just hasn't got intrinsic strength 
of its own.

Prasanna

sekhar le wrote:
> We use 5/0 prolene for all aortic purse strings. We use   finer 
> sutures with the idea that needle holes of bigger sutures cause more 
> bleeding   before   they are not tied.
> we do not use pledgets  with the idea that when there is bleeding the 
> pledgets obscure the  exact source of bleeding.
>
> With this approach we do not have problems in   normal sized aortas 
> but we do have occasional problems in thin large aortas.
>
> I would like to know what others use for large thin aortas.
>
>
> Dr Sekhar
>
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