Surgery for acute aortic dissection using moderate hypothermia and antegrade cerebral perfusion via the right subclavian artery
A. Temelkovska, I. Kajevski,
N. Hristov,Z. Mitrev
Special Hospital for Surgery
“ Filip Vtori”, Skopje, Macedonia
May, 2010
Cardiosurgery - Skopje

Acute aortic dissection (AAD) has one of the highest mortality rate in modern medicine, with a 68% mortality at 48 hours
The aim of surgery is to prevent aortic rupture, pericardial tamponade and to relieve aortic regurgitation, neurologic injury.
Various techniques have been proposed as means to protect the central nervous system. They all have both advantages and disadvantages
Cardiosurgery - Skopje


Cardiosurgery - Skopje

45 patients(44%) hemodynamic instable, shock, pericardial tamponade, myocardial ischemia or superior vena cava compression.
5 were (2,3%) comatose, 8 (4%) had newly developed transient ischemic attack, 1 patient had stroke
10 had(4,5%) visceral ischemia , limb ischemia in 15 (6,8%) and 6 (2,7%) presented with acute renal failure.
Cardiosurgery - Skopje

Diagnosis was made using:
1 patient MRI,
78 patients (80%) with CT,
103 (100%) patients TEE
50 (49%) DeBakey type II,
53 patients (51%) DeBakey type I
Mild/moderate aortic regurgitation was present 78 patients
(80%),severe aortic regurgitation in 25 patients (20%).
Preoperative ejection fraction was 50.7

6.8.
Cardiosurgery - Skopje

CEREBRAL PERFUSION VIA DIRECT CANNULATION
OF THE RIGHT SUBCLAVIAN ARTERY IN AORTIC DISSECTION
•Right subclavian artery antegrade body/ antegrade cerebral perfusion
•Snarred innominate artery
•Occlusion left carotid and subclavian artery
•Upper pressure limit 60-70 mmHg
•Flow rates 10ml/kg body weight
•Temperature 30 
C
•Retrograde blood cardioplegia
Cardiosurgery - Skopje

Cardiosurgery - Skopje

Early on, we performed 13 revisions due to bleeding.
We developed suction assisted bio glue application on the anastomosis lines, forcing the bio glue to impregnate the anastomotic site and needle holes.
As result, there was no re-exploration or early deaths as result of bleeding in the last 40 cases.
Mitrev Z, Interact Cardiovasc Thorac Surg. 2007
Cardiosurgery - Skopje

Additional procedures
AV suspension
AV replacement
18
1
ACBP
Table. 1 Operative techniques
Simple procedures
Tube graft replacement AA 1
Tube graft replacement AA
+ hemiarch
83
Total 84
3
Complex procedures
Tube graft replacement AA
+ total arch
Bentall AA + total arch
8
3
Bentall AA + hemiarch 3
Tirone David AA + hemiarch
Aortic root reconstr.+AV suspension+ AA + hemiarch
Total
10
3
27
Cardiosurgery - Skopje

Table.2 Extracorporal circulation data
ECC time, minutes, mean

SD
ACP time, minutes, mean

SD
ACP flow, ml, mean

SD
ACP pressure, mmHg, mean

SD
Nasopharyngeal temperature,

C, mean

SD
Tube graft replacement
+ AV resuspension
Complex procedures
105.6
24.7


16
6.5
862

113
71

6
30.8

2.4
223.6

53.2
35.6

22.3
ECC – extracorporal circulation, ACP- antegrade cerebral perfusion,SD – standard deviation
Cardiosurgery - Skopje

All patients but 10(10%) showed normal awakening within 8 hours postoperatively.
8 patients of the complex group had a fatal neurologic complication, the cause of coma and death was multiorgan failure and low cardiac output in 4pts, and bleeding in 2 patients.
5 patients had non-fatal neurologic complications.
Transient neurologic dysfunction, defined as postoperative confusion, agitation and delirium.
Cardiosurgery - Skopje

Average extubation time was 11.8

5.8 hours, except in 18 patients (19%) that required prolonged ventilation.
Average in hospital stay was 9.0

3.5, except in 17 patients (complex group) who required prolonged in-hospital stay.
Cardiosurgery - Skopje

Mortality rate of the complex group with cardiogenic shock was 27%
Mortality rate of the simple group was 4%
Cardiosurgery - Skopje

ACP via right subclavian artery enables safe period for circulatory arrest with effective cerebral perfusion, at the same time avoiding complications of the selective arch vessels cannulation.
Moderate hypothermia 30

C shortens the cooling and rewarming time, thus reducing the complications related to long pump times.
Dissection of the right subclavian artery was present in one patient, with succesfull cannulation and selective brain perfusion, and reconstruction of the artery following decannulation.
There were no malperfusion cases.
Cardiosurgery - Skopje

Direct subclavian artery cannulation for extracorporal circulation and antegrade perfusion using moderate hypothermia (30

), along with suction assisted bio glue application,is simple, fast and safe method for treatment of acute aortic dissection with excellent operative and early postoperative results
Cardiosurgery - Skopje