Technique
The patient is placed in the right lateral position. A left lateral thoracotomy is performed through the fourth or fifth intercostal space. Before manipulation to the descending aorta, the pericardium is incised and the location of the apex is confirmed by transesophageal echocardiography. Two pairs of pledget-supported 2-0 monofilament polypropylene sutures are placed on the apex, avoiding injury to the left anterior descending artery. An arterial cannula is inserted into the ascending aorta using the echocardiogram-guided Seldinger wire technique (Video 1). CPB is established by arterial cannulation via the apex and left femoral artery with venous drainage via the left femoral vein (Figure 1A). Once the bladder or rectal temperature has been cooled to 25ºC, potassium chloride is systemically administered instead of cardioplegia for myocardial protection during circulatory arrest. After clamping of the distal descending aorta, upper body perfusion is discontinued (circulatory arrest) and lower body perfusion is started via the left femoral artery. Retrograde cerebral perfusion is initiated using Takamoto’s technique.1 An apical cannula in the ascending aorta is used as a vent to ensure a bloodless operative field during proximal anastomosis (Figure 1B). After the proximal anastomosis using a branched vascular prosthesis, upper body perfusion is resumed through the branch of the prosthetic graft. The apical cannula is pulled back to the left ventricle and used as a ventricular vent during rewarming (Figure 1C). Distal anastomosis is performed after dividing the membrane separating the true and false aortic lumens. Once the distal anastomosis is completed, intercostal arteries are reimplanted if necessary.
From January 2014 to June 2020, we performed 17 replacements of the descending aorta with circulatory arrest for CBAD. Among these, we used transapical cannulation in six patients, including two who underwent emergency surgery for aortic rupture. No in-hospital death or major stroke occurred postoperatively (Table 1). No late deaths or aorta-related readmissions occurred during a mean follow-up period of 43 months.