[HSF] Aortic dissection and CPR-ascending aortic cannulation

Wed Sep 19 16:51:02 EDT 2007

Hal

The axillary artery is practically never too deep to sew a graft on. We use it very liberally, up to 200 cannulations here a year, and even in the most muscular of young men it is readily assessable through a 5 cm incision to either sew a graft (which is my preference) or cannulate directly with a specially designed short right angled axillary artery cannula developed I think by by Drs Ergin and Griepp and now marketed by Edwards. Dr Griepp advises strongly against cannulation using a guidewire as you risk intimal injury or dissection to the subclavian (which tends to be fragile) or arch, and also especially in the young marfanoids or older atherosclerotics the artery can literally fall apart and reconstructing this will become an operation in itself. We have abandoned attempts to cannulate the artery on a few occasions - generally because of injury to the vessel, but never because of depth or inaccessibility.

Ani

> To: OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] Aortic dissection and CPR-ascending aortic cannulation> Date: Mon, 17 Sep 2007 20:13:54 -0400> From: hgrmd at aol.com> CC: > > > Roberto,> >   I used the right axillary artery today on a Bentall.  He was a big guy, so I just placed the cannula via a guidewire through a pursestring.  His artery was quite deep with limited exposure.  I don't think I could have easily sewn a graft to the side of it.  He's doing well, though preop sleep apnea (on nightly BIPAP) precludes extubation until morning.> > > > Hal> > > -----Original Message-----> From: Dr. Roberto Battellini <battr at medizin.uni-leipzig.de>> To: OpenHeart-L at lists.hsforum.com> Sent: Mon, 17 Sep 2007 10:32 am> Subject: AW: AW: [HSF] Aortic dissection and CPR-ascending aortic cannulation> > > > > Mr Bachet writes axillary artery in page 980, I have the article in my> ands.Again, EJCTS 2007, June> he second choice is mine, taken from Urbanski who uses left carotid as> irst choice.> oberto> > ----Ursprüngliche Nachricht-----> on: openheart-l-bounces at lists.hsforum.com> mailto:openheart-l-bounces at lists.hsforum.com] Im Auftrag von David Harris> esendet: Samstag, 15. September 2007 23:00> n: OpenHeart-L at lists.hsforum.com> etreff: Re: AW: [HSF] Aortic dissection and CPR-ascending aortic> annulation> Did Dr Bachet not say on the HSF that his first choice> s innominate artery?> ave> > -- "Dr. Roberto Battellini"> battr at medizin.uni-leipzig.de> wrote:> > Please, read the comments of Dr Bachet in an> editorial of the European jour> Cardioth Surg 2007;31:979-81> First choice. Axillary, second: carotid. Look also> for Urbanski papers in> JTCVS and Annals about carotid cannulation.> Roberto> > -----Ursprüngliche Nachricht-----> Von: openheart-l-bounces at lists.hsforum.com> [mailto:openheart-l-bounces at lists.hsforum.com] Im> Auftrag von nand kejriwal> Gesendet: Freitag, 14. September 2007 08:32> An: OpenHeart-L at lists.hsforum.com> Betreff: Re: [HSF] Aortic dissection and CPR> > No Ani,> > I am not sure at all, because I have never used> transapical.However, it> should be quicker than femoral. The one advantage of> femoral I find is that> if the external massage is generating enough output,> we do not have to> discontinue it until we are on bypass.> > My understanding is that the surgeons who use> direct aortic cannulation do> so under TOE guidance to make sure that the cannula> is in the true lumen.> Perhaps in a desperate situation, one would like to> take a chance and hope> that it won't malperfuse.> > Nand> > On 9/14/07, Ani Anyanwu <anianyanwu at hotmail.com>> wrote:> >> > Nand> >> > Are you sure transapical is quickest? I would like> to hear from surgeons> > who actually use this approach in practice, but I> doubt that it would> truly> > be the quickest for surgeons not experienced in> its use. For what is> already> > a desperate tense situation, making an LV incision> and guiding a cannula> > into the aorta may not be as simple as it sounds.> >> > IMHO the quickest way if patient is in extemis or> malperfusing is to> > cannulate the dissection directly and as all> surgeons are used to the> > manouver of aortic cannulation they should be able> to effect it even in> > emergency. Several groups use direct cannulation> for all dissections and> > from what I understand it does not matter whether> the cannula ends up in> > true or false lumen provided the patient foes not> malperfuse (had one last> > year where on opening the cannula tip was clearly> in false lumen but the> > patient perfused okay).> >> > Ani> >> >> >> >> >> > > Date: Thu, 13 Sep 2007 21:43:45 +1200> From:> nkkejriwal at gmail.com> To:> > OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF]> Aortic dissection and> > CPR> CC: > > We had two patients in the unit who> arrested before reaching> > the OR. None of> them survived the repair.> Recently, I had another case> who> > arrested while> being transferred to theatre. He> was intubated and CPR> > continued. My initial> plan was to establish> bypass through femoral> vessels> > while someone else was> massaging. However even> external massage was not> > producing enough pressure> and this had been going> on for over 10 minutes.> > TEE revealed pericardium> full of blood with empty> heart. I did not> > proceed.> > John> > I agree that the quickest way> to institute bypass> would> > be transapical. What> cannula do you use?> Nand> >> On 9/11/07,> > jbflegejr at aol.com <jbflegejr at aol.com> wrote:> >> >> I have had salvage of> > two patients who ruptured while on the operating>> > table as they were> > prepared for anesthesia. They had not been> induced> > completely but we> > opened there sternum anyway. One had femoral> artery> > cannulation by a> > colleague, the other I cannulated through the> >> ascending aorta as> recently> > described by Curt Tribble. Both had no> >> neurologic sequale. In one> during> > the excitement I made the disal> > anastamosis a> bit tight in effect> causing> > an ascending aortic> > coarctation and he got> hemoytic anemia from> > intraluminal felt and a> > year or so later I> resected the area. If I> > encounter another case> > needing immediate> cannulation, I will cannulate> > the ascending aorta> > through the LV apex which> is quick and works well.> I> > had another> > patient who presented in the ER in> shock and with> hyperacute> > ischemic> > ECG changes across the anterior leads.> He had been worked up> and> > a> > diagnosis of ascending aortic aneurysm and> aortic insufficiency and>> >> > normal coronary arteries established and operation> scheduled for the> >> day> > after Christmas but he came back the day before> Christmas and went> >> > straight to the OR. He had a Type A dissection> extending into and> >> > obstructing the Left coronary. I replaced the> ascending aorta which> >> > relieved the coronary obstruction and replaced the> valve with a> >> > Starr-Edwards valve. This was 35 years ago. About> 25 years post op he> >> had> > a CT scan for some reason and the radiologist saw> that he had an> > aortic> > dissection down to the femorals and got rather> excited about it> > and> sent> > me the films. I did not recommend treatment. In> modern times> > this kind> of> > patient would have an aortic root replacement.> John Flege> >> >> >> > -----Original Message-----> > From:> tdmartin2000 at aol.com> > To:> > OpenHeart-L at lists.hsforum.com> > Sent: Mon, 10 Sep> 2007 9:06 pm> >> > Subject: Re: [HSF] Aortic dissection and CPR> >>> >> >> >> >> >> > Most of> > these pts with sudden deterioration have rupture> into their> >> pericardium>> > > and are not salvageable. I have attempted on> multiple occasions and> >> > have had 2> > that we got out of the OR only to> have anoxic cerebral> deaths.> > If they> > have> > tamponade, CPR does no good, as> you cannot fill. One of> > the ones we got> > out of> > the OR actually had> arrest right after> > induction of anesthesia and we> > were on> > pump> in under 10 min.> >> >>> >>> > > Tom Martin> >> > U of Florida> >> > Gainesville>> >> >> > -----Original> > Message-----> > From: james le> <jamesle2007 at yahoo.com>> > To:> > OpenHeart-L at lists.hsforum.com> > Sent: Mon, 10 Sep> 2007 6:35 am> >> > Subject: [HSF] Aortic dissection and CPR> >> >> >>> >> > We recently had a> > case of Aortic dissection transferred from some> >> other> > hospital for> > surgery. He had dissection aorta involving the> entire> > aorta along> >> >> > with severe AR.> > On arrival BP was 90 systolic,> all pulses palpable and> > there> > was no> > neurological deficit> > At ER> he suddenly developed> > severe Bradycardia and arrested and> >> resuscitation was unsuccessful. TEE> > done after death showed only> > small amount> > of> pericardial> collection.>> > == message truncated ===> > r. David G. Harris, FCS, MMED,> ardiothoracic Surgeon > uite 207 > uils River Private Hospital, > O Box 1200, Kuils River, 7579, Cape Town, South Africa. > el +27-21-9006411 > ax +27-21-9006412 Mobile +27-83-3309587> _______________________________________________> penHeart-L mailing list> Send postings to:> OpenHeart-L at lists.hsforum.com> To UNSUBSCRIBE, to CHANGE email address, or to view archives:> ttp://mmp.cjp.com/mailman/listinfo/openheart-l> All messages transmitted by the OpenHeart-L are subject to the policies and > isclaimers posted at:> ttp://www.hsforum.com/listdisclaim> ----------------------------------------> _______________________________________________> penHeart-L mailing list> Send postings to:> OpenHeart-L at lists.hsforum.com> To UNSUBSCRIBE, to CHANGE email address, or to view archives:> ttp://mmp.cjp.com/mailman/listinfo/openheart-l> All messages transmitted by the OpenHeart-L are subject to the policies and > isclaimers posted at:> ttp://www.hsforum.com/listdisclaim> ----------------------------------------> > > ________________________________________________________________________> Email and AIM finally together. You've gotta check out free AOL Mail! - http://mail.aol.com> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> -----------------------------------------
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