Carotid artery cannulation in acute aortic dissection with malperfusion

Abstract

Clinical Summary CASE 1. A 70-year-old man with a history of hypertension, coronary heart disease, and aortic valve defect experienced sudden thoracic pain 4 years after coronary artery bypass grafting and aortic valve replacement. Shortly after admission to our institution, he was lethargic and not responsive. A computed tomogram (CT)– angiograph of the aorta showed an extended acute aortic dissection involving supra-aortic branches and iliac arteries. The innominate artery and both carotid arteries showed severe compression of the true lumen by the false lumen (Figure 1). To avoid insufficient cerebral perfusion through the narrowed true lumen during cardiopulmonary bypass (CPB), we prepared the left common carotid artery through a separate incision on the neck and cannulated it with a 10-mm Dacron side graft. In turn, for sufficient perfusion of the rest of the body, a second arterial line was installed in the right femoral artery, which was dissection free. Both arterial lines were connected with a Y-shaped tube for arterial return from one pump. Distal aortic repair (hemiarch replacement) was performed during circulatory arrest in moderate hypothermia (28.0°C) by using unilateral cerebral perfusion through the cannulated carotid artery with a flow of about 0.8 L/min for brain protection. CASE 2. A 62-year-old man with a history of coronary heart disease and previous multiple coronary catheter interventions experienced sudden pain in the abdomen and lower extremities 4 days after the last coronary angioplasty. Both legs became pale and pulseless. A CT-angiograph showed an extended aortic dissection with massive compression of the true lumen by the false lumen in the abdominal aorta and the resulting malperfusion of the abdominal organs and lower extremities (Figure 2). Intrathoracic side-graft cannulation of the left common carotid artery allowed an antegrade perfusion of the true lumen during CPB. Aortic arch replacement with reimplantation of t h e i n nominate artery and the left common carotid artery was performed during circulatory arrest in moderate hypothermia (29.0°C), with brain protection achieved by using unilateral cerebral perfusion through the left carotid artery with a flow of about 1.0 L/min. After reinstitution of CPB, valvesparing ascending aortic replacement and coronary artery bypass grafting completed the procedure. In both cases the postoperative course was uneventful. The postoperative CT imaging showed a complete recession of the false lumen in the supra-aortic branches in case 1 and a nearly complete recession of the false lumen in the abdominal aorta in case 2 (Figures 1 and 2). Currently, about 3 years after the operation, both patients are well and have no clinical symptoms.