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Left Atrial to Femoral Artery Full Cardiopulmonary Bypass: a Novel Technique for Descending and Thoracoabdominal Aortic Surgery

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Left Atrial to Femoral Artery Full Cardiopulmonary Bypass: a Novel Technique for Descending and Thoracoabdominal Aortic Surgery Published online: 2019-12-09 Original Article 19 Left Atrial to Femoral Artery Full Cardiopulmonary Bypass: A Novel Technique for Descending and Thoracoabdominal Aortic Surgery Dimitra Papanikolaou, MD1 Chris Savio, BS, CCP1 Mohammad A. Zafar, MBBS1 Leon Freudzon, MD1 Jinlin Wu, MD1 Mohamed Abdelbaky, MD1 Keith J. Pelletier, MBA, MHS, CCP1 Joelle Buntin, MSN, RN, RN-BC1 Thais Faggion Vinholo, BS, MSc1 Bulat A. Ziganshin, MD, PhD1,2 Brian Schwartz, MS, CCP1 John A. Elefteriades, MD, PhD (Hon)1 1 Aortic Institute at Yale-New Haven Hospital, Yale University School Address for correspondence John A. Elefteriades, MD, Aortic Institute of Medicine, New Haven, Connecticut at Yale-New Haven, Yale University School of Medicine, Clinic Building 2 Department of Surgical Diseases, Kazan State Medical University, CB 317, 789 Howard Avenue, New Haven, CT 06519 Kazan, Russia (e-mail: [email protected]). Int J Angiol 2020;29:19–26. Abstract Left atrial-femoral artery (LA-FA) bypass with a centrifugal pump and no oxygenator is commonly used for descending and thoracoabdominal aortic (DTAA) operations, mitigating the deleterious effects of cross-clamping. We present our initial experience performing DTAA replacement under LA-FA (left-to-left) cardiopulmonary bypass (CPB) with an oxygenator. DTAA replacement under LA-FA bypass with an oxygenator was performed in 14 consecutive patients (CPB group). The pulmonary vein and femoral artery (or distal aorta) were cannulated and the full CPB machine were used, including oxygenator, roller pump, pump suckers, and kinetically enhanced drainage. The CPB group was compared with 50 consecutive patients who underwent DTAA replacement utilizing traditional LA-FA bypass without an oxygenator (LA-FA group). Perioperative data were collected and statistical analyses were performed. All CPB patients main- Keywords tained superb cardiopulmonary stability. The pump sucker permitted immediate ► descending aortic salvage and return of shed blood. Superb oxygenation was maintained at all times. replacement High-dose full CPB heparin was reversed without difficulty. The CPB group required ► thoracoabdominal markedly fewer blood transfusions than the LA-FA group (2.21 vs. 5.88 units, aortic replacement p < 0.004). The 30-day mortality rate was 7.1% (n ¼ 1) and there were no paraplegia ► cardiopulmonary cases in the CPB group versus 7 (14%) deaths and 3 (6%) paraplegia cases in the LA-FA bypass group. Traditional LA-FA bypass without an oxygenator avoids high-dose heparin. In the ► left atrial-femoral present era, heparin reversal is more secure. Our experience finds that the novel bypass applicationofLA-FACPBwithanoxygenatorissafeandsuggestsimprovedhemody- ► aortic surgery namics (immediate return of shed blood) and a hemostatic advantage (avoidance of This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. ► aortic aneurysm loss of coagulation factors in the cell saver). Since the pioneering report by Magovern in 1989,1 left heart the “clamp and sew” technique.2 Left heart bypass provides bypass with a centrifugal pump and no oxygenator has long visceral, spinal cord, and lower limb perfusion while the been established as the key strategy for distal aortic perfu- aorta is cross-clamped and requires only low-dose heparin- sion during descending and thoracoabdominal aortic (DTAA) ization. However, in this partial bypass circuit, intraoperative replacement operations, mitigating the deleterious effects of blood salvage is accomplished solely by means of a cell saver, published online Copyright © 2020 by Thieme Medical DOI https://doi.org/ December 9, 2019 Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0039-3400479. New York, NY 10001, USA. ISSN 1061-1711. Tel: +1(212) 760-0888. 20 LA-FA CPB with Oxygenator for Aortic Surgery Papanikolaou et al. which preserves red blood cells but does not prevent loss of returned to the pump. There is no delay inprocessing through a platelets, plasma, and coagulation factors.3 cell saver device for later transfusion. Also, the perfusionists The full cardiopulmonary bypass (CPB) circuit including can adjust the rate of left atrial drainage via roller pump as the oxygenator, roller pumps, and pump suckers has been needed to leave enough blood in the heart to provide the high proven to maintain oxygenation and hemodynamic stability upper body pressures required to optimize spinal cord perfu- during cardiac and ascending or descending aortic opera- sion. Theycan independentlyadjust theflow through the other tions and to provide immediate blood return to the patient, roller pump to maintain the desired level of lower body while preserving plasma and clotting factors.3 Aomi et al perfusion. This permits immediate, appropriate response to have previously reported a limited experience with DTAA blood loss and other causes of hemodynamic instability. repair using left heart bypass with a centrifugal pump, an Full heparinization is used. Flows are adjusted to maintain oxygenator, and a heat exchanger.4 The purpose of this article a good upper body pressure at or above 140 mm Hg during is to describe our initial experience performing DTAA re- the cross-clamp time and to provide 2 to 4 L lower body placement with a novel perfusion technique of left atrial- perfusion, dependent on body size. Left atrial return is femoral artery (LA-FA) or distal aortic full CPB with an adjusted to maintain these parameters. Immediate harvest- oxygenator, roller pump, and pump suckers. ing and return of shed blood is accomplished via the pump suckers. Methods Patient Population The circuit isshown in ►Fig. 1. Thetechniquewas conceived by our perfusionist (C.S.) after many years of performing conven- Fourteen consecutive patients underwent descending or thor- tional LA-FA partial bypass with a centrifugal pumpwithout an acoabdominal aortic replacement under LA-FA (left-left) CPB oxygenator. One-lung ventilation is instituted. Inflow is taken with an oxygenator (CPB group) between October 2017 and from the superior or inferior pulmonary vein with a right angle December 2018 at our institution. The CPB group was com- cannula (number 24, Edwards Lifesciences). Kinetic assisted pared with 50 consecutive patients who underwent DTAA venous (LA) drainage (KAVD) is a technique in which a roller replacement under traditional left heart bypass without an head is used to control the rate of venous flow. A number 24 oxygenator from February 2014 to October 2017 (LA-FA group). right angled cannula is connected to a primed 1/4″ line through Electronic medical records (EMRs) were reviewed to collect a roller pump on the heart–lung machine and returned to the patients’ demographics and comorbidities, as well as preoper- venous reservoir. Blood passes through an oxygenator and heat ative, intraoperative, and postoperative parameters, outcomes, exchanger and is propelled bya roller pump back to the FA. Our and complications. Institutional Review Board approval was perfusionists note that this system provides optimal hemo- obtained from Yale University’s Human Investigation Commit- dynamic and circulatory capabilities. Shed blood is automati- tee. Informed consent was waived due to the retrospective cally and immediately harvested into the pump suckers and nature of the study. This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. Fig. 1 Left atrial-femoral full cardiopulmonary bypass circuit. International Journal of Angiology Vol. 29 No. 1/2020 LA-FA CPB with Oxygenator for Aortic Surgery Papanikolaou et al. 21 Table 1 Patient demographics The Crawford classification with the Safi modification was used to assess the extent of thoracoabdominal aortic CPB group LA-FA group p-Value aneurysms,5 with the majority of TAAs falling under the n ¼ n ¼ ( 14) ( 50) (if applicable) most extensive type II category (N ¼ 6andN ¼ 10 for the Age at the 68.2 Æ 7.2 66.5 Æ 12.7 0.63 CPB and LA-FA groups, respectively). The maximal aortic time of diameter was 5.3 Æ 1 cm for the CPB group and 5.8 Æ 1.5 cm surgery for the LA-FA group (►Table 2). Female N ¼ 3 (21.4%) N ¼ 27 (54%) Medical and surgical history for both groups is shown in gender ►Table 3. Comorbidities were more prevalent in the CPB Height (cm) 173.5 Æ 11.2 168.4 Æ 9.9 0.1 group, as illustrated in ►Fig. 2, with the most significant Æ Æ Weight (kg) 86.07 16.9 76.7 17.8 0.08 difference observed in coronary artery disease, in 10 (71.4%) BMI (kg/m2) 28.6 Æ 4.7 26.9 Æ 5.1 0.28 patients in the CPB group and 17 (34%) patients in the LA-FA group (p ¼ 0.01). Six patients in the CPB group (42.9%) had a Abbreviations: BMI, body mass index; CPB, cardiopulmonary bypass; fi LA-FA, left atrial-femoral artery. con rmed family history of thoracic aortic disease as docu- mented by a relative having undergone imaging or surgical Statistical analysis was conducted using Fisher’s exact test repair, versus 9 (18%) patients in the LA-FA group (p ¼ 0.07). for categorical data and Student’s t-tests for continuous data. Furthermore, 9 (64.3%) patients in the CPB group and 40 Continuous variables are presented as mean Æ standard de- (80%) patients in the LA-FA group had a prior history of open viation and categorical variables are presented as numbers or endovascular aortic operation. Also, 3 (21.4%) and 13 (26%) and percentages. patients, respectively, had had a previous cardiac surgery Patient demographics for the two groups are shown in (non aortic). ►Table 1. The mean patient age was 68.2 Æ 7.2 years for the Æ CPB group and 66.5 12.7 years for the LA-FA group. Three Operative Data patients (21.4%) in the CPB group and 27 (54%) patients in the LA-FA group were female. The CPB group consisted of eight Operative data are summarized in ►Table 4.
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