Discussion
Complications associated with aortic cannulation can be potentially
catastrophic.2,3 In the event of aortic injury, prompt
recognition and management are critical. Multiple aortic cannulations
must also be avoided if the aorta has been partially denuded or
weakened.4,5
Repair can range from a small bovine or pericardial patch to total
ascending or arch replacement with prosthetic graft as dictated by the
degree of injury. For large tears or dissections, hypothermic
circulatory arrest is often needed as an adjunct.
Our technique blends both the patch and graft approaches, and it is
novel in that—rather than utilizing a circumferential Dacron tube
graft with a sidearm—we instead merely cut out the side-arm (with a
generous skirt) to serve as the patch. Our technique (1) allows for an
extended patch repair of the aorta rather than full aortic replacement
(2) consequently shortens the time needed for repair and/or circulatory
arrest and (3) simultaneously eliminates the need for a second arterial
cannulation site on already potentially comprised aorta. After the
repair was complete, the side-arm patch served as arterial inflow for
the bypass circuit. Given the small stature of this patient, the femoral
artery cannula was most likely providing little perfusion to her distal
limb. By converting to a central arterial inflow site, the patients leg
experienced greatly reduced ischemic time.
Potential disadvantages of this technique include the cost and wasted
material associated with off-label use of the commercially available
aortic graft. Additionally, our technique should only be employed for
aortic injuries without an extensive proximal or distal dissection, such
that the injured aorta can clearly be distinguished and excised to
provide a clean border of healthy aorta for anastomosis. Liberal
excision of the damaged aorta is critical for both confirming the
absence of dissection and ensuring an anastomosis that will tolerate
arterial inflow; longer-term efficacy or safety could otherwise be
compromised. The skirt size can be modified to accommodate larger
excisions while still avoiding a circumferential repair.
In conclusion, this strategy for managing aortic injuries is an easily
reproducible technique or “trick” to simplify the management of a
potential aortic cannulation disaster.