[HSF] Aortic purse strings in thin large aortas.

[prasannasimha]

Added it to the Wiki
Please read
http://ctsurgcomplications.wikia.com/wiki/Complications_related_to_Arterial_cannulation#Post_cannula_removal_bleed
and
http://ctsurgcomplications.wikia.com/wiki/Complications_related_to_Arterial_cannulation
and edit the page or please inform me of additions.
The axillary/innominate/iliac and rare forms of cannulation need to be 
worked on too.
Prasanna

jbflegejr at aol.com wrote:
> Your point about reducing the arterial blood pressure while tying the 
> suture is most important. To do this, I apply a clamp to the inferior 
> vena cava, when the systolic pressure is around 70, cinch the knot and 
> release the clamp at the same time, the whole sequence taking about 15 
> seconds. I think that a transverse incision is safer than a vertical 
> incision; former has less bursting force on the closure. Another way 
> of reducing the blood pressure, particularly when it is very high, is 
> ventricular pacing at a rapid rate, say 150, which will usually 
> abruptly produce a fall in pressure and is quickly reversible. John Flege
>
> -----Original Message-----
> From: prasannasimha at gmail.com
> To: OpenHeart-L at lists.hsforum.com
> Sent: Sat, 2 Dec 2006 10:38 PM
> Subject: Re: [HSF] Aortic purse strings in thin large aortas.
>
>    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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