Technique Of Circulatory Arrest Research Articles

Hypothermic Circulatory Arrest in Median Sternotomy Hemorrhage During Redo Aortic Surgery.

This study summarizes the clinical data of patients who developed sternotomy hemorrhage during redo aortic surgery and analyzes the clinical experience of using hypothermic circulatory arrest. We retrospectively analyzed the medical records of patients who developed sternotomy hemorrhage during redo aortic surgery from May 2018 to August 2021. General anesthesia with single-lumen tracheal intubation was used. Femoral artery, vein, and superior vena cava cannulation were used if cardiopulmonary bypass was required according to the situation, and right superior vein or apical cannulation was selected for left heart drainage. A total of 11 patients were enrolled in this study, comprising nine males and two females, with an average age of 44.3±16.7 years. All cases were successfully completed without cerebrovascular complications or paraplegia. Two patients died during hospitalization, two patients died during the follow-up after discharge, and the remaining patients are recovering well. The femoral-femoral bypass with hypothermic circulatory arrest technique is a safe and reliable method to use in cases of sternotomy hemorrhage during redo aortic surgery.

Organ damage evaluation in a temperature-controlled circulatory arrest rat model

BackgroundDeep hypothermic circulatory arrest (DHCA) is commonly used in adult aortic surgery and pediatric complex congenital heart disease, and is associated with pathophysiological changes and postoperative complications. Here, a temperature-controlled circulatory arrest model in rats was established to study the suitable temperature of circulatory arrest by investigating the damage to body organs under different temperatures.MethodsThirty Sprague‒Dawley rats were randomly divided into 5 equal groups for DHCA experiments: I (15–20 °C), II (20–25 °C), III (25–30 °C), IV (normothermic cardiopulmonary bypass), and V (sham operation group). Blood gas analysis, homodynamic parameters, and intervals of cardiac recovery were measured at different time points in all groups. Morphological changes in intestinal tissue were observed under light and electron microscopes. Oxidative stress was measured by MPO activity, MDA, and SOD content. Tissue damage was confirmed by serum detection of ALT, AST, BUN, Cr, and LDH. To examine the inflammatory response, cytokines, including IL-1, IL-4, IL-10, IFN-γ, and TNF-α, were detected.ResultsThe extracorporeal circulation technique caused damage to the body; the degree of the damage caused by the circulatory arrest technique may be related to circulating temperature, with the least amount of damage occurring at 20–25 °C compared to 15–20 °C and 25–30 °C. Ischemia and hypoxia can cause intestinal tissue damage, which manifests primarily as a loss of the intestinal mucosal barrier. Ischemic intestinal damage caused by DHCA was not associated with inflammation.ConclusionThe study provides new insights into the pathophysiologic mechanisms of DHCA.

Protective effect of Tulbaghia violacea extract on cardiac damage: deep circulatory arrest rat model

Objectives: Total circulatory arrest (TCA) technique is a method used in cardiac surgery accompanied by cardiopulmonary bypass (CPB). It has been shown that Tulbaghia violacea extract increases antioxidant capacity, regulates blood pressure, decreases lipid peroxide, and reduces atherosclerosis. In this experimental study, we aimed to investigate the effect of T. violacea extract administration on serum oxidative stress parameters (Total antioxidant status [TAS], total oxidant status [TOS] and oxidative stress index [OSI] and deoxyribonucleic acid [DNA] damage level with 8-Hydroxy-2-Deoxyguanosine [8-OHdG]) and histopathological changes in the heart and other organs in rats with deep circulatory arrest model. Methods: In this study, 48 Wistar Albino adult rats, 24 female and 24 male, obtained from Harran University Experimental Animals Research Center were used. The average weight of female rats was 250-300 g, and the average weight of male rats was 450-500 g. These rats were randomly divided into four groups. 6 male and 6 female rats were used in each group (Group 1 = Sham, Group 2 = Injury, Group 3 = Treatment and Injury, Group 4 = Treatment). Results: As a result of this experimental study, the changes in the biochemical 8-OHdG, TOS, OSI and TAS levels of the groups were found to be statistically significant (p < 0.001). In the subgroup analyzes of the data, 8-OHdG level, which is an oxidative DNA damage marker in Group 2 was higher than the Group 1, Group 3 and Group 4 and there was a statistically significant difference (p < 0.001, p = 0.027 and p < 0.001; respectively). The TOS level of the injury group was higher than Group 1, Group 3 and Group 4 and there was a statistically significant difference (p < 0.001, p = 0.003 and p < 0.001; respectively). Conclusions: As a result of our study, we revealed that T. violacea extract has a protective effect on organ and tissue damage in the TCA model.

Antepartum acute Stanford type A aortic dissection: a case report and literature review

BackgroundAortic dissection in pregnancy is a life-threatening event that is associated with high maternal and foetal mortality. Most cases occur during the third trimester of pregnancy, Herein, we describe a case of a pregnant woman with acute type A aortic dissection at 28 weeks of gestation.Case presentationA previously healthy, 24-year-old gravida 2 para 1 woman was brought to the emergency department during at the 28 weeks of gestation and diagnosed with acute type A aortic dissection. Cesarean section was performed with the cardiac surgical team on standby for cardiopulmonary bypass and the patient delivered a baby weighing 1000 g. After the operation, we performed the Beatall procedure and total arch replacement with FET using the deep hypothermic circulatory arrest technique. Both the mother and child survived and recovered well. A review of the literature on antepartum acute aortic dissection during pregnancy is also presented.ConclusionWomen should have a comprehensive, systematic physical examination before getting pregnant. Women at high risks of aortic dissection must undergo multidisciplinary evaluation and be counseled before pregnancy, once they become pregnant, their consistent aortic root diameter should be consistently monitored, and their blood pressure strictly controlled.

Energy Level and Success of Internal Defibrillation for Shockable Rhythm during Cardiopulmonary Bypass in Cardiac Surgery: A Retrospective Study

Internal defibrillation is commonly indicated for shockable rhythm following cross-clamp removal in cardiac surgery. Low energy decreases the success rate of defibrillation but high energy can cause myocardial damage. This study aimed to determine the success rate of internal defibrillation for shockable arrhythmias after cardiac surgery.Retrospective data of 1,424 patients who developed shockable rhythms (ventricular fibrillation or ventricular tachycardia), and required internal defibrillation after aortic cross-clamp removal during cardiac surgery, without deep hypothermic circulatory arrest technique, from August 2015 to July 2017, were reviewed.The overall success rate of internal defibrillation in the first attempt of defibrillation was 61.5%. The success rate of the energy levels at 30, 10, and 7 Jules were 66.7, 64.9, and 61.5%, respectively. The success rate was higher in patients who had a better ejection fraction than those who failed after defibrillation. This was significantly associated with higher pH, higher bicarbonate, lower serum calcium, and lower total cardioplegic volume during cardiopulmonary bypass (CPB). Redo-valve surgery, valvular surgery, and combined coronary artery bypass graft with valvular surgery had a non-significantly lower success rate (p-value = 0.989). Incidence of failure for defibrillate patients in redo-valvular surgery, combined coronary artery bypass graft with valve surgery, adult congenital heart defect, and valvular surgery; requiring four or five shocks was non-significantly increased. Recurrent rate of ventricular fibrillation/ventricular tachycardia was 13.5%.The success rate of internal defibrillation was not related to the dose of energy used after being weaned off CPB.

A Modified Hypothermic Circulatory Arrest Technique Improves Early and Near-Midterm Results in Patients with Acute Type A Aortic Dissection.

The hypothermic circulatory arrest (HCA) is an indispensable step in the surgical treatment of an acute type A aortic dissection (ATAAD), which could greatly affect the postoperative outcome. We modified the HCA technique and validated the feasibility and superiority of the new approach relative to the conventional method. Eighty-eight patients with ATAAD were enrolled in this study between May 2016 and April 2018. Of those, 36 patients in the Conventional treatment group had circulatory arrest at 25°C for about 16-28 minutes, while 52 patients in the Modification group underwent a circulatory arrest at 28°C for only 1-3 minutes. The preoperative clinical data and postoperative clinical outcomes were compared between the two groups. No intraoperative mortality occurred in any of the cases. No significant differences were observed in the aortic cross-clamp times during the cardiopulmonary bypass (CPB) between the two groups. In the Modification group, several indicators, such as mechanical ventilation time, postoperative 48-h drainage volume, blood transfusion volume, the ICU-stay time and postoperative hospital stay, were reduced significantly as compared with those in the Conventional group. Whereas three postoperative deaths in the hospital occurred in the Conventional treatment group, all the patients in the Modification group were cured. There is no difference in the incidence of postoperative complications between the two groups. The patients had a 100% follow up with a mean of 17 ± 6 months. A moderate hypothermia with a short circulatory arrest is a safe and effective HCA approach that provides satisfactory early and near-midterm results in the patients who received ATAAD treatment.

The first Case of Circulatory Arrest in deep Hypothermia in Cardiac Surgery in Mali

The authors report the case of circulatory arrest in deep hypothermia during the closure of an arterial duct associated with significant mitral insufficiency for mitral replacement in an underdeveloped country such as Mali. This circulatory arrest technique used in major European and American heart surgery centers for the management of complex heart disease. It constitutes a real challenge for us to report the first case of circulatory arrest in the management of the persistent arterial canal associated with mitral insufficiency including simple operative consequences.

Avoiding use of total circulatory arrest in the practice of congenital heart surgery.

Deep hypothermic circulatory arrest (DHCA) technique has been an important armamentarium in the correction of congenital heart diseases. There have been many controversies and concerns associated with DHCA, particularly neurological damage. Selective ante grade cerebral perfusion (SACP) was introduced as an adjunct to DHCA with the objective of limiting the neurologic injury during aortic arch repairs. Over the past two decades, various aspects of cardiopulmonary bypass and DHCA have been studied and modified such as optimisation of flows, anti-inflammatory interventions, haematocrit, and temperature to improve neurologic outcomes. With the changes in practice of DHCA, outcomes have significantly improved but SACP intuitively appears attractive to offer better neuroprotection. The strategy of conduct of SACP is evolving and needs to be standardised for comparing outcomes. In this review we have discussed the various physiological and technical factors involved in conduct of SACP in paediatric cardiac surgery and outcomes with SACP.

Short-term outcomes of modified Y-graft technique in acute type a aortic dissection using the femoral artery bypass and one minute systemic circulatory arrest technique

ObjectiveAortic arch replacement in acute type A aortic dissection patients remains the most challenging cardiovascular operation. Herein, we described our modified Y-graft technique using the Femoral Artery Bypass (FAB) and the One Minute Systemic Circulatory Arrest (OSCA) technique, and assessed the short-term outcomes of the patients.MethodsBetween February 2015 and November 2017, 51 patients with acute type A aortic dissection underwent aortic arch replacement. Among them, 23 patients underwent FAB while 28 patients underwent both FAB and OSCA. The intraoperative data and postoperative follow-up data were recorded. The follow-up data of patients with traditional Y-graft technique were collected from previously reported studies.ResultsIn the FAB group, two patients died due to pulmonary infection (30-day survival rate, 91.3%), and two patients were paralyzed from the waist down. Hemodialysis was performed for five patients (21.7%) before hospital discharge. Fifteen patients (65.2%) received respiratory support for more than 2-days and eight patients (34.8%) for more than 5-days. These follow-up results were comparable or better than the patients with traditional Y-graft technique. Furthermore, compared to the FAB group, the morbidity due to neurological dysfunction and acute renal failure was significantly reduced in the FAB+OSCA group. Moreover, the respiratory support, length of postoperative stay and ICU stay were shortened.ConclusionsThis study clarified the feasibility of FAB and OSCA technique in modifying Y-graft technique. The acute type A aortic dissection patients showed less surgical complications and favorable short-term outcomes after this surgery.

Short-Term Outcomes of Modified Y-Graft Technique in Acute Type A Aortic Dissection Using the Femoral Artery Bypass and One Minute Systemic Circulatory Arrest Technique

Objective: Aortic arch replacement in acute type A aortic dissection patients remains a most challenging cardiovascular operation. This article aims to show our Modified Y-Graft Technique using the Femoral Artery Bypass (FAB) and the One Minute Systemic Circulatory Arrest (OSCA) Technique and assess the short-term outcomes of the patients. Methods: Between February 2015 and November 2017, 51 patients with acute type A aortic dissection underwent aortic arch replacement. Among them, 23 patients' procedure used FAB and 28 patients utilized both FAB and OSCA. The intraoperative data and postoperative follow-up data were recorded. The follow-up data of patients with traditional Y-graft technique were collected from previous reported studies. Results: In FAB group, two patients died for pulmonary infection (30-day survival rate 91.3%), and two patients paralyzed from the waist down. The hemodialysis was performed for five patients (21.7%) before hospital discharge. Fifteen patients (65.2%) received more than 2-day's respiratory support and 8 patients (34.8%) received more than 5-day's respiratory support. These follow-up data are basically flat or precede to the patients with traditional Y-graft technique. Furthermore, compared to the FAB Group, the morbidity of the neurologic dysfunction and the acute renal failure was significantly reduced in FAB+OSCA Group. Besides, the respiratory support, the length of the postoperative stay and the ICU stay were shortened. Conclusions: This study clarified the feasibility of FAB and OSCA technique in modifying Y-graft technique. The acute type A aortic dissection patients tend to have less surgical complications and favorable short-term outcomes by this surgery. Funding Statement: The study has no funding. Declaration of Interests: The authors declare no conflict of interest. Ethics Approval Statement: All procedures performed in studies involving human participants were approved by the Ethics Committee of Qilu Hospital of Shandong University.

Selective cerebral perfusion with aortic cannulation and short-term hypothermic circulatory arrest in aortic arch reconstruction

The deep hypothermic circulatory arrest (DHCA) technique has been used in aortic arch and isthmus hypoplasia for many years. However, with the demonstration of the deleterious effects of prolonged DHCA, selective cerebral perfusion (SCP) has started to be used in aortic arch repair. For SCP, perfusion via the innominate artery route is generally preferred (either direct innominate artery cannulation or re-routing of the cannula in the aorta is used). Herein, we describe our technique and the result of arch reconstruction in combination with selective cerebral and myocardial perfusion (SCMP) and short-term total circulatory arrest (TCA) (5-10 min) through ascending aortic cannulation. Thirty-seven cases with aortic arch and isthmus hypoplasia accompanying cardiac defects were operated on with SCMP and short TCA in Baskent University Istanbul Research and Training Hospital between January 2007 and Sep 2012. There were 17 cases with ventricular septal defect (VSD)-coarctation with aortic arch hypoplasia (CoAAH), 4 cases of transposition of the great arteries-VSD-CoAAH, 4 cases of Taussing Bing Anomaly-CoAAH, 2 cases complete atrioventricular canal defect-CoAAH, 3 cases single ventricle-CoAAH, 3 cases of type A interruption-VSD, 2 subvalvular aortic stenosis-CoAAH and 2 cases of isolated CoAAH. The aorta was cannulated in the middle of the ascending aorta in all cases. The cross-clamp was applied to the aortic arch distal to either the innominate artery or the left carotid artery. In addition, a side-biting clamp was applied to the descending aorta. The aorta between these two clamps was reconstructed with gluteraldehyde-treated autogeneous pericardium, using SCMP. The proximal arch and distal ascending aorta reconstructions were carried out under short TCA. The mean age of the patients was 2.5 ± 2 months. The mean cardiopulmonary bypass and cross-clamp times were 144 ± 58 and 43 ± 27 minutes, respectively. The mean SCMP and descending aorta ischemia times were 22.6 ± 4.8 and 27 ± 6.3 minutes, respectively. Mean TCA time was 7.6 ± 2.1 minutes (min: 4, max 10 min). The mean in-hospital stay time was 8.6 ± 1.9 days. None of the cases operated with this technique had neurological defects. The mortality rate was 2.7% (1 patient). SCMP with aortic cannulation and short TCA (under 10 minutes) in aortic reconstruction is safe and practical in this high-risk patient group.

A propensity score–matched comparison of deep versus mild hypothermia during thoracoabdominal aortic surgery

By using deep hypothermic circulatory arrest and non-deep hypothermic circulatory arrest approaches, we examined the impact of distal ischemia time and temperature on intra-abdominal reversible adverse outcomes and permanent adverse outcomes during descending thoracic aortic and thoracoabdominal aortic aneurysm operations. A retrospective review of all patients who underwent descending thoracic aortic and thoracoabdominal aortic aneurysm repair between January 2002 and December 2008 was undertaken, including relevant preoperative, intraoperative, and postoperative data, and followed by a propensity score-matched analysis. Of the total of 262 patients, 240 had data complete enough to permit analysis, and 90 were suitable for the propensity-matched study. Reversible adverse outcomes included renal failure, liver failure, and temporary hemodialysis. Permanent adverse outcomes included paraplegia, permanent hemodialysis, and 30-day mortality. Thirty-day mortality was 7.1% (17/240). Overall, reversible adverse outcomes developed in 40.8% of patients and permanent adverse outcomes developed in 10% of patients. The propensity score analysis identified statistically significant decreased odds of developing reversible adverse outcomes in patients undergoing deep hypothermic circulatory arrest (odds ratio, 0.32; confidence interval, 0.12-0.85). Specifically, significantly lower rates of acute renal failure (22% vs 46.4%, P=.03) and liver failure (17.8% vs 34.3%, P=.04) were observed in the deep hypothermic circulatory arrest group compared with the non-deep hypothermic circulatory arrest group. In addition, there were decreased odds of reversible adverse outcomes (odds ratio, 0.22; confidence interval, 0.06-0.79) developing in patients with a stage II elephant trunk procedure. During descending thoracic aortic and thoracoabdominal aortic aneurysm repairs, the use of deep hypothermic circulatory arrest results in improved postoperative adverse outcome rates compared with non-deep hypothermic circulatory arrest techniques. The development of reversible adverse outcomes is strongly associated with the development of permanent adverse outcomes.

COMPORTAMENTO DA FREQUÊNCIA CARDÍACA E DA TEMPERATURA CORPÓREA EM COELHOS SUBMETIDOS À PARADA CIRCULATÓRIA CARDÍACA

The technique of total circulatory arrest (TCA), or inflow occlusion , consists in preventing the blood entry into the heart chambers by clamping the vena cava and the cranial and caudal vena azygos. However, changes in physiological parameters of the patient can be triggered with the application of this technique. This technique can be easily used in heart intra-cavity diseases, whose correction takes a few minutes, as in pulmonary stenosis or subaortic stenosis. Because low cost and simple implementation, it may be carried out in private clinics. In this trial, the behavior of heart rate and body temperature of rabbits submitted to two periods of five minutes of TCA, by the use of inflow occlusion technique, was evaluated. A period of blood recirculation between occlusions was performed to verify the potential benefits of this practice on the behavior of heart rate and body temperature of the animals. These parameters were assessed throughout the perioperative period. There were two deaths, both in the recirculation period due to the occurrence of ventricular fibrillation. Nevertheless, with the implementation of the period of blood recirculation, we verified that this technique can be used in intra-cardiac surgery lasting up to 10 minutes. KEYWORDS: Circulatory arrest, inflow occlusion, rabbits.

The Clinical Outcome of Pulmonary Thromboendarterectomy for the Treatment of Chronic Pulmonary Thromboembolism

Background: Diagnosing chronic pulmonary embolism at an early stage is difficult because of the patient’s nonspecific symptoms. This condition is not prevalent in Korea, and in fact, there have been only a few case reports on this in the Korean medical literature. We analyzed the surgical outcome of performing pulmonary thromboendarterectomy in patients with chronic pulmonary embolism. Material and Method: The study subjects included those patients who underwent surgery for chronic pulmonary embolism from 1996 to 2008. For making the diagnosis, echocardiography, chest CT and a pulmonary perfusion scan were performed on the patients who complained of chronic dyspnea. Result: Pulmonary endarterectomy was performed as follows: by incision via a mid-sternal approach (7 patients); by incision via a left posterolateral approach (1 patient); using the deep hypothermic circulatory arrest technique (4 patients); under ventricular fibrillation (3 patients); and under cardioplegic arrest (1 patient). The postoperative systolic pulmonary artery blood pressure significantly decreased from a preoperative value of 78.9±14.5 ㎜Hg to 45.6±17.6 ㎜Hg postoperatively (p=0.000). The degree of tricuspid regurgitation was less than grade Ⅱ after surgery. Two patients died early on, including one patient who had persistent pulmonary hypertension without improvement and right heart failure. Conclusion: Patients who have chronic pulmonary embolism are known to have a poor prognosis. However, we think that early surgical treatment along with making the proper diagnosis before the aggravation of right heart failure can help improve the quality of a patient’s life.

Safety of Unilateral Antegrade Cerebral Perfusion at 22°C Systemic Hypothermia

The superiority of antegrade cerebral perfusion (ACP) in aortic surgery is widely accepted, but the sufficiency of unilateral cerebral perfusion and the optimal systemic temperature during the operation are still controversial. Thirty patients who underwent operation with unilateral ACP at a systemic temperature of 22 degrees C between January 2005 and September 2007 were included in this study. The mean age (+/-SD) of the patients was 58 +/- 11 years, and 21 (70%) of the patients were male. The indication for surgery was acute type A aortic dissection in 14 patients (47%), degenerative aortic aneurysm in 9 patients (30%), dissecting aortic aneurysm in 6 patients (20%), and intramural hematoma in 1 patient (3%). Supracoronary ascending aorta replacement was performed in 13 patients (43%). Eight patients (27%) underwent ascending aorta and hemiarch replacement. The Bentall procedure was performed with hemiarch replacement in 3 patients (10%). Three patients (10%) underwent total aortic arch replacement, and 2 patients (7%) underwent the Bentall procedure. The ascending aorta, aortic arch, and descending aorta were replaced in 1 patient (3%). Hospital mortality was limited to 1 patient (3.3%). A permanent or transient neurologic deficit was not detected in any of the survivors. The mean cardiopulmonary bypass, aortic cross-clamp, and ACP times were 144 +/- 40 minutes, 82 +/- 28 minutes, and 30 +/- 11 minutes, respectively. The mean mechanical ventilation time was 18 +/- 9 hours. The mean stay in the intensive care unit was 2.3 +/- 1.1 days, and the mean hospital stay was 12 +/- 6 days. Unilateral ACP with systemic hypothermia at 22 degrees C is safe and has satisfactory clinical results. Establishing ACP via cannulation of the right axillary artery is fast and simple. The presence of fewer cannulas in the operation field provides an operative condition as convenient as the deep hypothermic circulatory arrest technique.

Treatment of complex pathologies of the aortic arch with a new combined surgical and endovascular technique

Aims: We evaluated the application of a new combined surgical and endovascular technique for the treatment of the aortic arch. The technique is used to treat extensive aortic disease by a single-stage procedure. Surgical outcomes and follow-up data are summarized and analyzed. Methods: Between August 2005 and July 2007, ten patients (54±11,7 years; 8 male, 2 female) with aortic pathologies (7 dissections, 3 aneurysms) underwent replacement of the ascending aorta and the aortic arch, and simultaneous stent graft implantation into the descending aorta. The stent graft was implanted using the E-vita open endoluminal stent graft, employing the technique of circulatory arrest and moderate hypothermia with selective antegrade cerebral perfusion. The stent graft was deployed under visual guidance through the open aortic arch into the true lumen. Results: Intraoperative antegrade stenting of the descending aorta combined with the distal ascending aorta and aortic arch repair was performed successfully in all patients; a survival rate of 100% was achieved. Two patients had a postoperative neurological deficit but recovered almost completely. Seven patients had fully thrombosed perigraft spaces within 11 days, while two patients showed complete obliteration of the false lumen at the three-month control. Conclusion: The combined surgical and endovascular technique described in this report proved feasible for the treatment of extended aortic lesions. It serves as an additional option for aortic repair in a single-stage method and is associated with no elevated risk for the patient.

Combined Surgical and Endovascular Repair of Complex Aortic Pathologies With a New Hybrid Prosthesis

We evaluated the application of a new combined surgical and endovascular technique for the treatment of thoracic aortic aneurysms and dissections. The technique is used to treat extensive aortic disease by a single-stage procedure. Surgical outcomes and follow-up data are summarized and analyzed. Between August 2005 and December 2006, 7 patients (2 women), aged 62 +/- 11 years, with aortic pathologies (5 dissections, 2 aneurysms) underwent replacement of the ascending aorta and the aortic arch and simultaneous stent graft implantation into the descending aorta. The stent graft used was the E-vita open endoluminal stent graft (Jotec Inc, Hechingen, Germany), which was implanted using the technique of circulatory arrest and moderate hypothermia with selective antegrade cerebral perfusion. The stent graft was deployed under visual guidance through the open aortic arch into the true lumen. Intraoperative antegrade stenting of the descending aorta combined with the distal ascending aorta and aortic arch repair was performed successfully in all patients. The survival rate was 100%. One patient had a postoperative neurologic deficit but recovered completely. Four patients had fully thrombosed perigraft spaces within 11 days, whereas 1 patient showed complete obliteration of the false lumen at the 3-month control. The combined surgical and endovascular technique described in this report proved feasible for the treatment of extended aortic lesions. It serves as an additional option for aortic repair in a single-stage method and is associated with no elevated risk for the patient.

V-03.09: Partial circulatory arrest and cardio-pulmonary bypass for removing IVC thrombus extending up to right atrium

The standard surgical treatment for removing an IVC thrombus extending upto the right atrium involves cardio-pulmonary bypass, exsanguination and deep hypothermic total circulatory arrest. The whole process is complicated involving major risks especially deep hypothermia related coagulopathy. We have carried out two such procedures on cardio-pulmonary bypass involving a technique of partial circulatory arrest and avoidance of deep hypothermic circulatory arrest and exsanguination.

Limiting Circulatory Arrest Using Regional Low Flow Perfusion

Deep hypothermic circulatory arrest (DHCA) is commonly used for neonatal cardiac surgery. However, prolonged exposure to DHCA is associated with neurologic morbidity. The Norwood operation and aortic arch advancement are procedures that typically require DHCA during surgical correction. Regional low flow perfusion (RLFP) can be used to limit or exclude the use of circulatory arrest. This technique involves cannulation of the innominate or subclavian artery using a Gore-Tex graft, allowing isolated cerebral perfusion. Data was collected in 34 patients undergoing either neonatal aortic arch reconstruction or the Norwood procedure using RLFP. All patients had two arterial pressure monitors using either the umbilical or femoral artery catheters and radial or brachial catheters. Adequacy of perfusion was determined using cerebral saturation, blood flow velocity, mean arterial pressures, and arterial blood gas results. Cerebral saturation and blood flow velocity were monitored using the near-infrared spectroscopy (NIRS) (INVOS 5100, Somanetics Corp, Troy, MI) and a transcranial Doppler pulse-wave ultrasound (TCD) (EME Companion, Nicolet Biomedical, Madison, WI), respectively throughout the entire bypass period. Blood gases were monitored using a point of care blood gas analyzer (Gem Premier, Mallinckrodt Sensor System, Inc., Ann Arbor, MI). Data collected revealed total bypass times for repair between 69–348 min, with a mean of 180 min. Regional low flow perfusion times lasted between 6–158 min, with an average of 50 min., and DHCA times ranged from 0–66 min, with a mean of 19 min. The perfusion techniques used allowed patient clinical data to remain consistent throughout the cardiopulmonary bypass period, regardless of lower flows (Figure 1) The 30-day postoperative mortality rate was 2.9 %, with no evidence of neurologic injury during follow up. In conclusion, regional low flow cerebral perfusion might benefit patients by limiting the use of circulatory arrest during cardiac surgery. Further study is necessary to evaluate patient outcomes, comparing regional cerebral perfusion and circulatory arrest techniques.

Inferior Vena Cava Thrombus Removal Using Hypothermic Circulatory Arrest in Two Patients with Osteosarcoma

In this case report, the technique of deep hypothermia and circulatory arrest (DHCA) is used to successfully extract extensive symptomatic tumor thrombus from the inferior vena cava (IVC) in two patients with osteosarcoma. This is the first description of the use of this modality for treatment of osteosarcoma involving the IVC. Osteosarcoma and the use of DHCA are discussed.