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.