[HSF] Aortic purse strings in thin large aortas.

[Mitch Lirtzman]

I've been using 2-0 pledgeted Ethibond for 25 years, and maybe need to 
reinforce it once or twice a year. I use the IVC trick on occasion using 
one click of a large aneurysm clamp (non-occlusive) and start sewing as 
soon as the BP starts to drop. Release the clamp when you begin to tie and 
the pressure will be normal with your last throw. No need to wait for 
anesthesia to jerk around with dilators and then pressors. Don't forget to 
warn anesthesia.
Mitch Lirtzman
Lafayette, La. At 02:29 AM 12/3/2006, you wrote:
>Another trick to drop the BP for a while is to clamp the IVC. Release it 
>slowly as if it is released quickly, the BP tends to come back very quickly.
>
>>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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>
>--
>Ben Bidstrup FRACS FRCSEd FEBCTS
>Consultant Cardiothoracic Surgeon
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