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.