Discussion
Although several reports have revealed the safety and durability of
descending aorta replacement using deep hypothermic circulatory arrest,2 open surgery for CBAD has been shown to have
considerable risks of cerebrovascular complications. 3Because retrograde perfusion is a potential cause of intraoperative
cerebrovascular events, we apply transapical aortic cannulation for
patients with poor vascular access, shaggy aorta, or partial thrombosis
of the false lumen. Shiiya et al.4 reported a case of
thoracoabdominal aortic repair with apical cannulation and stated that
apical cannulation was advantageous in terms of preventing retrograde
thrombotic events. Takemura et al.5 reported the
usefulness of transapical cannulation to prevent malperfusion in the
treatment of an acute traumatic descending aortic rupture. The
advantages of transapical cannulation include antegrade perfusion, true
lumen perfusion, and quick establishment of CPB. 6 The
apex is easy to expose and access via left thoracotomy, and a guidewire
and cannula can be easily visualized with transesophageal
echocardiography. Some surgeons establish CPB before thoracotomy in
patients with aortic rupture. However, we safely canulated the apex and
established CPB in two patients with aortic rupture. In those patients,
we initially performed a small left anterior thoracotomy and extended
the thoracotomy laterally after establishment of CPB.
Another advantage of apical cannulation is that the apical cannula can
be used as a vent, as described above. Venting the ascending aorta
during circulatory arrest with Takamoto’s technique provides a bloodless
operative field for the proximal anastomosis. Additionally, the apical
cannula can be used as a left ventricular vent during rewarming by
pulling it back to the left ventricle.
Although there are risks of apical bleeding and pseudoaneurysm after
apical cannulation, a previous study showed low incidences of those
complications,7 and secure surgical procedures can
prevent them.8 No re-exploration for bleeding or
apical pseudoaneurysm occurred among our six patients.
In conclusion, apical cannulation is a useful option in open repair of
the descending aorta for CBAD.
Conflict of interests: The authors have no conflicts of
interest to declare.