Brandon E. Ferrell, MD, and Joseph J. DeRose, MD
Montefiore Medical Center, Bronx, 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 Thomas J. Zeyl MD and Tomas D. Martin MD.
Essential Operative Steps
- Appropriate patient identification
- Lines and monitoring
- General endotracheal anesthesia
- Intraoperative TEE
- Right axillary artery dissection
- Heparinization for axillary artery conduit (100 u/kg)
- Axillary anastomosis with 8mm Dacron graft
- Median sternotomy
- Dissect prepericardial fat/thymus to expose innominate vein
- Open pericardium, pericardial well, survey ascending aorta/arch for pathology
- Systemic heparinization (400 u/kg)
- Arterial cannulation
- Venous cannulation
- Retrograde cannula in coronary sinus
- Check ACT (>480 seconds)
- Initiate CPB and cooling
- LV vent placement
- Aortic crossclamp
- Cardioplegia if associated AI via retrograde cardioplegia and ostial antegrade
- Complete aortotomy with resection of ascending aorta to sinotubular junction.
- Once electrocerebral silence and adequate temperature, place the patient in Trendelenburg, turn cardiopulmonary bypass
off and remove aortic cannula and crossclamp - Complete resection of aorta into the arch and as far as needed to get to normal aorta, create beveled graft with sidearm
- Snare innominate artery and initiate antegrade cerebral perfusion
- Distal anastomosis
- Release snared innominate artery, and begin reperfusion through sidearm on graft
- Rewarm
- Proximal anastomosis to sinotubular junction
- Deairing via root with slotted needle, retrograde cardioplegia
- Remove aortic crossclamp
- Check for hemostasis
- Atrial and ventricular pacing wire placement
- Chest tube placement
- Check for air, remove LV vent, then wean from CPB
- Remove root vent and venous cannula
- Protamine administration for heparin reversal
- Ligate graft sidearm
- Clamp, divide, and oversew axillary graft
- Assess hemostasis
- Sternotomy closure
- Closure of axillary cannulation site
Potential Complications and Pitfalls
- Axillary artery or brachial plexus injury
- Stay midline during sternotomy
- Avoid injury to innominate vein and aneurysmal aorta during initial dissection/creation of pericardial well
- Cannulation catastrophe (dissection, bleeding, right atrial tear)
- Improper venous cannula positioning
- Coronary sinus injury with retrograde cardioplegia cannulation
- Poor choice of crossclamp location
- Iatrogenic dissection from antegrade cardioplegia cannula
- Inadequate cerebral protection or unilateral cerebral perfusion
- Improper graft length
- Cooling/warming too quickly
- Air embolism from improper deairing of the arterial graft
- Inadequate deairing of heart prior to removal of aortic root vent
- Acquired coagulopathy and bleeding
Tips:
The axillary artery is fragile, and it is easy to create an iatrogenic dissection. To prevent injury with anastomosis, good exposure
is necessary. The axillary vein can be retracted, and the pectoralis minor muscle divided, with little consequence, to assist with
such exposure.
In cases that use selective cerebral perfusion, care must be made to ensure a complete Circle of Willis. If there is no backflow
from the left common carotid artery, an incomplete Circle of Willis needs to be suspected. A perfusion catheter can be placed
in the left common carotid artery to perfuse the left hemisphere of the brain.
To prevent improper graft length, prior to the proximal anastomosis it is best to pressurize the clamped distal graft with pump
flow and the clamped proximal graft with cardioplegia.
If air embolism or iatrogenic dissection is suspected, see chapter 69 on ‘Unexpected Intraoperative Complications’ for further
details on the essential steps to take.
Template Dictation
Preoperative Diagnosis: [INDICATION – e.g. size and extent of aneurysmal disease]
Postoperative Diagnosis: Same (with appropriate adjustments)
Indications: Current guidelines follow the indications for ascending aneurysm repair, and hemiarch replacement is often
performed when the ascending aneurysm extends into the proximal aortic arch.
- Maximal aortic diameter ≥5.0cm sporadically
- Aneurysm growth ≥ 0.5cm/year
- Maximal aortic diameter ≥4.5cm with a diagnosis of Marfan / EDS Type IV (vascular)
i. Reasonable to consider repair if maximal cross-sectional area (cm2) divided by patient’s height ratio >10, or if the
diameter is >4.0cm in women with Marfan contemplating pregnancy - Maximal aortic diameter ≥ 4.2cm with a diagnosis of Loeys-Dietz syndrome
- Maximal aortic diameter > 4.5cm with family history of aortic dissection
- Maximal aortic diameter of >4.8cm in the setting of bicuspid aortic valve
- Length of ascending aorta of >12cm when measured from the innominate artery to the aortic annulus
- Patients develop compressive symptoms (hoarseness, dysphagia, dyspnea, chest or back pain) with known aneurysm
i. Aneurysm rupture can present with chest pain, shoulder pain or hemoptysis and warrants emergent surgical
intervention
Replacing the hemiarch at the time of aortic root or ascending aortic aneurysm repair has also been thought to mitigate the risk
of future aortic aneurysm recurrence. In this scenario, the need for hypothermic circulatory arrest and the risk of perioperative
mortality and stroke needs to be strongly considered. A hemiarch may also be considered if the area for crossclamping on the
ascending aorta is thin and friable or calcified making an open anastomosis safer.
Procedure(s) Performed: Ascending Aorta with Hemiarch Replacement with DHCA using a [DETAILS – Size of Graft]
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [SEX] with a history of [DISEASE – size of aneurysmal disease, and or rate of
growth of aneurysm]. Preoperative CT scan revealed [FINDINGS].
Description of the Procedure: The patient was taken to the operating room and [HIS/HER] identity and planned procedure
verified. The patient was placed on the operating room table in the supine position and general anesthesia was
obtained. Hemodynamic catheters were inserted, and transesophageal echocardiogram was performed to evaluate cardiac and
valve function. The patient was prepped and draped in the usual sterile fashion.
A right infraclavicular incision was made. Dissection was carried through the pectoralis fascia, and the axillary vein was
exposed and retracted. The axillary artery was identified and isolated. 100 u/kg of heparin was systemically administered.
Proximal and distal control of the axillary artery was obtained. A longitudinal arteriotomy was made and a standard 5-0 prolene
running anastomosis was performed in an end-to-side fashion to an 8mm Dacron graft.
The chest was entered via standard median sternotomy. The heart was exposed, and the ascending aorta was inspected and
showed [OPERATIVE FINDINGS]. The patient was systemically heparinized with a total of [UNITS] of systemic
heparin. The right atrial cannulation sutures were then placed in the right atrium. The antegrade cardioplegia sutures were
placed in the ascending aorta. The retrograde cardioplegia sutures were placed in the right atrium and the left ventricular vent
sutures were placed in the right superior pulmonary vein. The ACT and systemic pressure were confirmed, and the right axillary
conduit was cannulated, secured and deaired. A dual-stage venous cannula was then placed and secured in the right atrium. A
retrograde catheter was placed into the coronary sinus and secured. The patient was placed on cardiopulmonary bypass,
eventually cooled to [BLANK]oC, and electrocerebral silence was achieved. Upon fibrillation, a vent was placed in the left
ventricle via the right superior pulmonary vein. The aortic crossclamp was placed and antegrade cardioplegia was administered
upon which there was rapid arrest of the heart. This was followed by retrograde cardioplegia. The aorta was opened just
proximal to the crossclamp, and the ascending aorta was resected to just superior to the sinotubular junction with visualization
of the right and left coronary ostia. Once the patient reached approximately [BLANK]oC and electrocerebral
silence, [HE/SHE] was placed in Trendelenburg position and the pump was turned off. The crossclamp was removed. The
ascending aorta was transected cephalad, and the aorta was resected all the way up into the aortic arch, including all diseased
aorta in the arch, until there was noted to be relatively normal sized aorta. The innominate artery was snared and antegrade
cerebral perfusion initiated. Backflow was observed from the left common carotid artery. A [SIZE]mm side-arm graft was
chosen and beveled to fit the transverse arch. The graft was sewn end-to-end to the underneath side of the aortic arch utilizing
a running 3-0 prolene suture. Upon completion of the anastomosis, bioglue was utilized on the graft to cover needle holes. The
side-arm was then connected to the arterial line through a regular tubing connector. After deairing the graft, the graft was
clamped, the innominate artery snare was released, and reperfusion was begun. A crossclamp was applied proximal to the
joining of the side-arm. Cerebral ischemia time was [TIME] minutes. Antegrade cerebral perfusion time was [TIME]
minutes. Rewarming was begun. The graft was cut to the appropriate length and anastomosed end-to-end to the proximal aorta
utilizing a running 3-0 prolene suture. This was done right at the sinotubular junction. Upon completion, bioglue was placed
on the graft to cover suture holes. The heart was deaired in the routine fashion utilizing active suction in the aortic root and the
left ventricle. Retrograde cardioplegia was given. The crossclamp was removed. The patient was rewarmed to [BLANK]oC.
Atrial and ventricular pacing wires were then inserted and tested for appropriate capture. A [NUMBER]Fr chest tube was
placed in the mediastinum and large Blake drains in the [LEFT/RIGHT] pleural space. The heart was deaired, and the LV
vent was removed after minimal air was seen by TEE. The patient was weaned from cardiopulmonary bypass. The venous
cannula was removed, and the cannulation sutures were secured. Protamine was administered and the patient was monitored
for adverse reactions. Coagulopathy was assessed and hemostasis secured. The aortic side-arm was clamped and cut. The
remaining stub of the side-arm was closed with a 3-0 prolene suture and 2 large clips placed at the base. The axillary graft was
clamped, divided, and oversewn with 5-0 prolene in two layers. The operative field was thoroughly inspected for bleeding.
Once adequate hemostasis was achieved, the sternum was closed with a total of [NUMBER] stainless steel sternal wires
utilizing a figure of eight interlocking fashion. Vancomycin powder was placed in the wound prior to sternal closure. The fascia
was then closed with #1 vicryl suture in running fashion. The deep dermal layer was then closed with 2-0 vicryl suture in
running fashion. The skin and subcuticular layer was closed with 4-0 monocryl in running fashion followed by Dermabond on
the skin.
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, but stable condition.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of this procedure.
NOTE: Aortic surgery, including that of the arch, may vary from institution to institution. Cannulation strategies and cerebral
protection can be completed differently. Alternatively, antegrade cerebral perfusion can also be given with direct innominate
cannulation. The aorta can be cannulated directly in either the ascending aorta or the aortic arch. The arterial cannula is “y”ed
off and a small arterial cannula (10Fr BioMedicus) can be placed into the innominate artery through a pursestring suture of 5-
0 prolene.
When selective antegrade cerebral perfusion is given, it is important to carefully deair the innominate artery into the aortic arch
prior to gently clamping or snaring it. Confirming good retrograde flow through the left carotid is important for confirming a
patent Circle of Willis. Cerebral saturations are also helpful in confirming appropriate perfusion to both cerebral hemispheres.
It is important to snare or gently clamp the left carotid during selective antegrade cerebral perfusion to pressurize the left
cerebral hemisphere and ensure appropriate perfusion.
The repair can also be performed with retrograde cerebral perfusion or under isolated deep hypothermic circulatory arrest. If
retrograde cerebral perfusion is planned, a 4-0 prolene pursestring suture is placed in the SVC and it is cannulated with a rightangled soft tip cannula directed cephalad towards the right internal jugular vein. The SVC is snared around the tip of the canula.
In this scenario, a central venous pressure of 15-25mmHg on circulatory arrest is desired to avoid cerebral edema at higher
pressures.
Multiple Choice Question(s)
A 47-year-old female previously diagnosed with Marfan syndrome is found to have a 5.4cm ascending aortic aneurysm on CT
extending into the proximal aortic arch. She is planned for an ascending aortic and hemiarch replacement. The right axillary
artery and right atrium are cannulated. The patient is cooled to 24oC, and the aortic crossclamp applied. The ascending aorta is
resected proximal to the aortic crossclamp. After removal of the aortic crossclamp, the innominate artery is clamped, the patient
is separated from cardiopulmonary bypass, and antegrade cerebral perfusion is started at 10mL/kg/min. No backflow is noted
from the left common carotid artery. The next best step is:
A. Perform an emergent carotid-carotid bypass
B. Insert a cannula in the superior vena cava for retrograde cerebral perfusion
C. Reapply the aortic crossclamp and restart CPB
D. Insert a perfusion catheter to the left common carotid artery
E. Convert to a total arch replacement
Answer: D. Selective cerebral antegrade perfusion via the axillary or innominate artery travels antegrade up the right vertebral
and common carotid arteries to perfuse the brain. A complete Circle of Willis allows for perfusion of the left hemisphere. The
patient described here likely has an incomplete Circle of Willis since blood flow is not seen returning down the left common
carotid artery. When this occurs, a balloon occludable perfusion catheter can be quickly placed in the left common carotid
artery and bilateral cerebral perfusion can be maintained. This can also be advantageous in patients with carotid artery stenosis.
In this patient, the distal anastomosis could also be completed under isolated deep hypothermic circulatory arrest as there is no
consensus of the superiority of cerebral protection strategies and it is often based on institution/surgeon preference. Converting
to retrograde cerebral perfusion or reapplying the crossclamp does not address the incomplete Circle of Willis.
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2015 Nov 1;36(41):2779]. Eur Heart J. 2014;35(41):2873-2926.
Jassar AS, Vallabhajosyula P, Bavaria JE, et al. Direct innominate artery cannulation: An alternate technique for antegrade
cerebral perfusion during aortic hemiarch reconstruction. J Thorac Cardiovasc Surg. 2016;151(4):1073-1078.
MacGillivray TE. How I Teach Hemi-Arch Replacement. Ann Thorac Surg. 2016;101(4):1251-1254.
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