Michael Simpson, MD and Hiroo Takayama MD, PhD
Columbia University Irving Medical Center, New York, NY, USA
This chapter is a revision and update of that included in the previous edition of the TSRA Operative Dictations in
Cardiothoracic Surgery written by Tom P. Theruvath, MD, PhD, and John S. Ikonomidis, MD, PhD.
Essential Operative Steps
- ECG, pulse oximetry, bilateral upper extremity arterial monitoring, central venous access
- Induce general anesthesia
- Mark midline chest incision and bilateral groins for possible arterial access if needed
- TEE, Foley, PA catheter, end-tidal CO2, temp probe for skin and core temp (we use nasopharyngeal and rectal probes),
bihemispheric cerebral oxygen saturation monitoring, arterial line in radial (right radial if axillary perfusion is planned) - Prep and drape to include thorax, infraclavicular areas, neck, and both legs circumferentially
- Placement of 5Fr left femoral arterial catheter for pressure transduction and emergent arterial access for bypass
- Pass CPB lines and prime circuit. Prepare head vessel perfusion lines/catheters
- Median sternotomy with 1-2cm extension cranially to supraclavicular notch. Extend liberally if complex arch repair is
needed - Dissection superior to innominate vein to visualize innominate artery and evaluate arch to determine whether total or just
proximal transverse (hemiarch) arch needs to be replaced. Encircle the innominate vein with umbilical tape to aid in
visualization - Encircle the innominate artery and left common carotid artery with vessel loops
- Confirm absence of pericardial effusion/hemopericardium and prepare to control hypertension once opening pericardium.
Prepare pericardial well and assess root/proximal ascending aorta to decide whether root needs to be reconstructed - Systemic heparinization (300 u/kg) and confirmation of ACT >480 seconds
- Use epiaortic ultrasound to identify an area of the aorta with minimal dissection involvement to ensure safe true lumen
cannulation. Cannulate this area using Seldinger technique and an appropriately sized EOPA (elongated one-piece
arterial) cannula. Use TEE to confirm presence of wire in the true lumen of the descending aorta - Cannulate right atrial appendage with dual stage venous cannula and position tip in IVC
- Cannulate the SVC if retrograde cerebral perfusion is planned
- Place coronary sinus catheter and LV vent via the right superior pulmonary vein
- Commence bypass and cool to 24oC (cool to 28oC for planned hemiarch replacement)
- Apply aortic crossclamp and infuse del Nido cardioplegia retrograde via the coronary sinus catheter until arrest is
achieved. Transect the aorta at the STJ and infuse Delnido cardioplegia antegrade ostially to the coronary arteries - While cooling, inspect the aortic valve and determine involvement of the aortic root in the dissection and the need for
root replacement with aortic valve-sparing operation or aortic valve replacement - Size the proximal graft needed for STJ plication. If the entry tear is in the root or there is significant aneurysmal
degeneration, aortic root replacement with reimplantation or replacement of the aortic valve will be necessary - Once the temperature reaches 24 oC, position the patient in Trendelenburg and begin circulatory arrest. Start retrograde
cerebral perfusion, aiming for CVP 15-20mmHg to deair the cerebral vasculature - Remove the aortic crossclamp and trim the aorta distally
- Place balloon tip catheters into the innominate artery and the left common carotid artery with a metal bulldog clamp and
begin antegrade cerebral perfusion at 10-15cc/kg/min. End retrograde cerebral perfusion. Confirm adequacy of cerebral
perfusion with bilateral cerebral oximetry monitors. For hemiarch replacement, we begin with unilateral antegrade
cerebral perfusion via the innominate artery. However, if saturations are low, we place a second balloon tip catheter in
the left common carotid artery and give bilateral antegrade cerebral perfusion - Identify the intimal tear and assess the distal arch and takeoff of the head vessels for aneurysmal dilation and intimal
fragility to determine the extent of arch replacement - Resect the appropriate level of arch tissue for the appropriate replacement
- For total arch replacement, we favor use of a Gelweave multibranch graft to facilitate head vessel anastomosis and
perfusion via another sidearm. Perform distal anastomosis in two layers of 3-0 prolene with felt strip outside of the aorta.
The multibranch graft also provides additional landing zone for future TEVAR, if necessary - Cannulate the graft through the sidearm and deair, before resuming lower body perfusion
- Complete proximal aortic valve repair or aortic root replacement if required. For STJ plication, use a short segment of
Gelweave graft and anastomose this to the STJ using 4-0 prolene in mattress fashion. Tie these sutures over an
appropriately sized Hegar dilator (usually 25mm) - Trim the arch graft for anastomosis to the STJ graft. Trim enough to prevent graft kinking
- Fill the heart and deair the graft using an 18G needle and remove the crossclamp
- Complete head vessel anastomoses. For a multibranch graft, use the 10mm branch for the innominate and 8mm for left
common carotid and left subclavian artery (where applicable). End antegrade cerebral perfusion and remove perfusion
catheter in innominate artery prior to completion of anastomosis - Deair head vessel grafts and resume perfusion
- After the temperature reaches 36°C, wean and terminate CPB. Give protamine and decannulate
- We ligate the perfusion branch and any unused branches with heavy silk ties and large vascular clips. The presence of
large vascular clips helps identify these branches on future imaging and prevents misidentification as a pseudoaneurysm - Ensure hemostasis and close the chest as usual, with placement of mediastinal drains
Potential Complications and Pitfalls
- Management of pericardial effusion/cardiac tamponade: careful induction of general anesthesia with prep prior to
induction; controlled opening of the pericardium is key, with anesthesia prepared to manage hypertension - Inability to place antegrade cardioplegia/root vent cannula due to anterior wall dissection involvement: place coronary
sinus catheter for retrograde cardioplegia delivery, with planned ostial cardioplegia delivery after arrest and transection
of aorta - No region for safe true lumen central cannulation: Then consider axillary artery or femoral artery for central true lumen
cannulation in a peripheral artery. In extreme scenarios, samurai cannulation might be considered - Organ (especially cerebral) malperfusion and need for alternative arterial cannulation site: presentation with cerebral
malperfusion with dissection at the innominate/carotid orifice may necessitate neck exploration or axillary arterial
cannulation - Left-sided cerebral oximetry below 70% on initiation of antegrade cerebral perfusion: use a second balloon-tip catheter
to directly cannulate the left common carotid artery and begin bilateral antegrade cerebral perfusion - Severe aortic insufficiency, aortic root dilation, or entry tear including the aortic root: necessitates aortic root replacement
with valve replacement or valve reimplantation (valve sparing root replacement) in carefully selected patients. This
scenario also requires careful and deliberate temperature management to prevent refractory ventricular fibrillation due to
rapid cooling – especially with massive aneurysms or reoperations where the aorta cannot be immediately crossclamped - Dissection involves coronary arteries: will usually require aortic root replacement and may require coronary bypass. If
there is concern for incomplete myocardial protection from this complication, give additional cardioplegia down the
bypass graft - Improper deairing: deair the graft after distal anastomosis by allowing it to fill with blood through gentle side arm
perfusion prior to clamping and resuming full flow. Prior to removing the crossclamp, deair the proximal graft portion
with an 18-gauge needle - Persistent visceral or lower limb malperfusion after ascending/arch repair: may require endovascular therapy such as
TEVAR or branch stenting postoperatively. If performing partial arch replacement or total arch replacement, multibranch
portion of graft can afford additional landing zone - Too long of conduit: can consider a plication suture on the lesser curvature of the graft to shorten the proximal portion of
graft and relieve kinking. This may require the surgeon to re-apply the crossclamp, shorten, and re-anastomose the endto-end ascending aorta graft - Bleeding from anastomoses: be prepared with hemostatic adjuncts, both topical and systemic products. Pericardialpledgeted sutures can also be used at graft anastomoses
Template Dictation
Preoperative Diagnosis: Acute Type A Aortic Dissection
Post-operative Diagnosis: Same (with appropriate adjustments)
Procedure(s) Performed: Repair of ascending and zone 2 aortic arch replacement [OR HEMIARCH] for acute type A aortic
dissection utilizing moderate hypothermic circulatory arrest and [BILATERAL/UNILATERAL] selective antegrade cerebral
perfusion.
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Operative Findings: A [SIZE]cm ascending aorta with friable tissues and a dissection flap visualized in the mid arch.
[SIGNIFICANT TOTAL TRANSVERSE AORTIC ARCH HEMATOMA/INTIMAL FRAGMENTATION/OR
SIGNIFICANT ANEURYSMAL ENLARGEMENT WAS DEMONSTRATED NECESSITATING TOTAL ARCH
REPLACEMENT]. The aortic valve was competent and trileaflet. Aortic insufficiency was secondary to commissural
detachment.
Description of Procedure: With the patient in supine position under general anesthesia with monitoring lines in place, the
chest, abdomen, and lower extremities circumferentially were prepped and draped in sterile fashion. Cardiopulmonary bypass
lines were passed and primed. A median sternotomy was made and extended slightly cranially in the midline towards the neck
through which the innominate vein was identified and retracted with vessel loops. TEE confirmed the absence [PRESENCE]
of a pericardial effusion. The pericardium was opened in inverted-T fashion and extended upwards to expose the entire
ascending aorta. A pericardial well was created. The innominate artery and the left common carotid arteries were dissected and
encircled with vessel loops. The patient was systemically heparinized. Using epiaortic ultrasound, a site on the ascending aorta,
where an access to the true lumen could be obtained, was selected for cannulation. The aorta was cannulated with a 20Fr EOPA
cannula [RANGE 18-24Fr] using Seldinger technique. TEE confirmed the presence of the wire in the true lumen of the distal
aorta. The arterial cannula was deaired and connected to the bypass circuit. A dual-stage venous cannula was positioned and
secured through the right atrial appendage and attached to the venous side of the pump oxygenator. The SVC was cannulated
with a 24Fr metal tip right angle cannula and attached to the venous end of the bypass circuit. Following confirmation of an
ACT >460-480 seconds and completion of retrograde autologous priming, cardiopulmonary bypass was commenced and
systemic cooling to 24°C was initiated. A left ventricular vent was inserted via the right superior pulmonary vein and a coronary
sinus catheter was inserted for delivery of retrograde cardioplegia. Cerebral perfusion catheters were systematically deaired.
Ice packs were placed around the patient’s head. The heart was arrested by placement of a crossclamp at the distal ascending
aorta and with delivery of cardioplegia retrograde via the coronary sinus catheter and antegrade via direct cannulation of the
coronary ostia. Cardioplegia was re-dosed per protocol.
The ascending aorta was transected in its midportion. The intimal tear was found just above the STJ. The proximal portion of
the aneurysm was then dissected free and removed to the level of the sinotubular junction. At this point, it was possible to
inspect the aortic valve and it was found to be a competent tricuspid aortic valve without pathologies. Both left and right
coronary ostia were unobstructed and without involvement of the dissection flap.
At this time, the patient’s systematic temperature had reached 24°C. Attention was turned to the arch. Circulatory arrest was
commenced and the aortic crossclamp was removed. Retrograde cerebral perfusion was commenced via the SVC cannula to
maintain CVP 15-20mmHg. A balloon-tip catheter was placed into the innominate artery and the left common carotid artery
was clamped with a metal bulldog. Antegrade cerebral perfusion was begun at 8-12cc/kg/minute. Retrograde cerebral perfusion
was stopped. Cerebral oximetry confirmed adequate saturation bilaterally. The distal ascending aorta was resected, exposing
an additional intimal tear in the mid arch. The aorta was resected just past the takeoff of the left common carotid artery,
including the intimal tear. A 30mm Gelweave multibranch graft was brought onto the operative field after being soaked in
rifampin. Its distal end was trimmed and anastomosed to Zone 2 of the arch with a double layer of running 3-0 prolene suture
reinforced with a felt strip. After completion of the anastomosis the graft and lower body were perfused through the graft side
branch, after flushing any debris. Attention was turned back to the aortic root. A short segment of 28mm Gelweave graft was
anastomosed to the STJ with 4-0 prolene mattress sutures. These sutures were tied over a 25mm Hegar dilator in order to
downsize the STJ and repair the aortic valve. This anastomosis was reinforced with an additional layer of running 4-0 prolene.
The proximal end of the arch graft was trimmed and anastomosed to the STJ ring with running 4-0 prolene suture. Full
rewarming was started. An 18-gauge needle was placed in the graft and the crossclamp was removed after deairing maneuvers.
The patient resumed normal sinus rhythm spontaneously. The left common carotid was trimmed to healthy tissue, and was
anastomosed to an 8mm branch with 5-0 prolene, reinforced with a felt strip. Another 8mm branch was ligated with heavy silk
sutures and 2 metal clips were applied. Finally, the innominate artery was trimmed to healthy tissue, and was anastomosed to
the 10mm branch of the graft with 5-0 prolene, reinforced with a felt strip. The perfusion catheter was removed at the end of
the anastomosis. Ventricular pacing wires were placed on the inferior surface of the right ventricle and the patient was weaned
from CPB. Once the systemic temperature had reached 36°C, the cannulae were removed with uneventful protamine
administration. Hemostasis was obtained and confirmed at all cannulations, anastomoses, and dissection sites. The perfusing
side branch was ligated with metal clips and heavy silk suture. A 28Fr mediastinal chest tube was left in the mediastinum
followed by a 19Fr Blake drain in the posterior pericardium. The sternum was closed with a total of [NUMBER] stainless steel
wires followed by wound irrigation and closure of fascia, soft tissue, and skin anatomically with running absorbable sutures in
layers. The skin was cleaned, and sterile dressings applied. The sterile drapes were removed, and the patient was transferred to
the Cardiothoracic Intensive Care Unit in critical, but stable, condition having tolerated the procedure well.
All instrument, sponge, and needle counts were confirmed to be correct, twice, at the end of the operation. The patient was
subsequently transferred to the postoperative cardiac surgical intensive care unit in critical condition.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of this procedure.
PERFUSION DATA: Cardiopulmonary bypass time was [BLANK] minutes with a crossclamp time of [BLANK] minutes
and a hypothermic circulatory arrest time with selective antegrade cerebral perfusion of [BLANK] minutes.
Multiple Choice Question(s)
What is the most common site of intimal tear in acute type A aortic dissection?
A. Proximal ascending
B. Descending aorta
C. Coronary ostia
D. Aortic arch
Answer: A. the most common intimal tear site is in the proximal ascending aorta, approximately 2-2.5 cm above the aortic
root. The next most common locations are the aortic arch and just distal to the origin of the left subclavian artery
