Cannulation of the left common carotid artery for proximal aortic repair

Abstract

The proper selection of a suitable arterial cannulation site is of great importance in aortic surgery, especially in the presence of dissection. The use of the common carotid artery for the arterial inflow offers the possibility of antegrade flow during cardiopulmonary bypass and selective cerebral perfusion during aortic arch repair. Clinical Summary I have used this technique in 6 patients in whom a femoral cannulation was not feasible. The heart and the proximal aorta were exposed through a median sternotomy. After mobilization of the innominate vein, the proximal segments of the arch vessels were isolated (the left common carotid artery up to a length of 3 to 4 cm). In only 1 case with extensive dissection of the aorta including all supraaortic branches, the left common carotid artery was prepared via a separate incision in the neck. After heparinization, the exposed segment of the carotid artery was crossclamped; a longitudinal incision was carried out; and an 8- or 10-mm vascular polyester graft was anastomosed to the artery with a continuous 5-0 polypropylene suture. For this purpose, a piece of a side branch of the vascular graft for later aortic replacement was used (InterGard Hemabridge with 1 side branch or InterGard Aortic Arch with 4 side branches; InterVascular, La Ciotat, France). After connection of the arterial line and cannulation of the right atrium, cardiopulmonary bypass was started with normal flow (about 2.4 L/min/m 2 of body surface). Because all 6 patients in whom this cannulation technique was used had aortic dissection (5 acute type A dissections and 1 persistent dissection after replacement of the ascending aorta in acute type A dissection), reconstruction was begun with the distal aortic repair. After the rectal temperature had fallen to about 26°C, the arch arteries were clamped as far distally as possible from their origins. The left common carotid artery was clamped immediately proximal to the cannulation site, and an incomplete circulatory arrest, with selective cerebral perfusion at a flow rate of a 500 to 1000 mL/min, was instituted without crossclamping the aorta. The perfusion pressure was limited to not more than 100 mm Hg. In addition to ice packs placed around the head, thiopental and cortisone were used for pharmacological brain protection. After resection of the aortic arch, an end-to-end anastomosis between the vascular graft and the descending aorta was carried out with a continuous 4-0 polypropylene suture (in 1 case using the elephant trunk technique). In 4 cases the arch arteries were transected distally to their origins and anastomosed end-to-end with the side branches of the aortic arch graft (InterGard Aortic Arch, InterVascular) with continuous 5-0 polypropylene sutures. After completion of the anastomoses to the left subclavian and the left common carotid artery, the clamps on both vessels were opened, the aortic arch graft clamped proximal to the reimplanted arteries, and cardiopulmonary bypass resumed with full flow. After anastomosing the brachiocephalic artery to the Dacron graft, the clamp was shifted proximally. In 2 patients the arch arteries were excised as a longitudinal patch and anastomosed with the Dacron graft (InterGard Hemabridge, InterVascular) using a continuous suture. Subsequently, proximal aortic repair was carried out using our own techniques. 1-3 A valve-sparing aortic root repair was performed in 3 patients, and complete replacement or re-replacement of the ascending aorta and the aortic valve with a self-assembled mechanical or biological composite graft was carried out in another 3 patients. Before termination of cardiopulmonary bypass, the arterial line was switched from the carotid artery to a side branch of the vascular graft. The Dacron graft anastomosed with the left common carotid artery was severed near the anastomosis and oversewn. No neurological complications occurred in any of the patients. A 67-year-old schizophrenic with acute aortic dissection in association with Marfan’s syndrome, however, had to be reintubated because of respiratory insufficiency and kept on long-term ventilation. This patient was transferred to a rehabilitation clinic, and the remaining patients were discharged home. At present, all patients are alive and well.