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 Sanford Zeigler, MD.
Essential Operative Steps
- Preoperative planning for CPB cannulation
- Induction, intubation, lines, and monitoring
- Bilateral radial arterial pressure line
- Neuromonitoring (cerebral oximetry, transcranial Doppler, EEG)
- Intraoperative TEE
- Right axillary artery dissection
- Systemic heparin (100 u/kg)
- Axillary anastomosis with 8mm Dacron graft
- Median sternotomy
- Divide thymus, encircle innominate vein, and retract for exposure of the aortic arch
- Dissect out innominate artery, encircle with silastic
- Open pericardium, create pericardial well
- Dissect out left carotid, left subclavian, and encircle with silastic
- Mobilize PA from aorta for crossclamp; completely encircle ascending aorta
- Full heparinization (400 u/kg)
- Right axillary conduit cannulated, secured, deaired
- 3-0 prolene pursestring to RA; venous cannulation with two stage cannula; connect to circuit
- Place cardioplegia cannulae – root vent to ascending aorta, retrograde through coronary sinus
- Confirm ACT >480 seconds
- Initiate CPB
- Initiate systemic hypothermia to 24oC (bladder temperature) or cooler depending on more distal work, degree of difficulty
- Place right superior pulmonary vein vent
- Aortic crossclamp, antegrade cardioplegic arrest with ~1L cold blood cardioplegia
- CPB flows 2-2.5L/min/m2
- Cardioplegia is administered retrograde and directly down the coronary ostia at intervals throughout the case
- Resect diseased ascending aorta to crossclamp (alternatively a no touch technique can be used where the crossclamp is
not applied to the aorta. Instead, the distal anastomosis is performed first under DHCA and antegrade cerebral
perfusion/retrograde cerebral perfusion) - Give hydrocortisone, phenobarbital, mannitol, lasix
- Drop flow to 10mL/kg/min
- Clamp innominate proximal to graft
- Remove aortic crossclamp
- Ensure backflow from left carotid, clamp if adequate
- Add arterial perfusion balloon (pediatric retrograde) to left carotid if inadequate cerebral flow
- Resect aortic arch, leaving 1cm Carrel buttons around arch vessels
- Size proximal descending aorta; open and prepare multi-branch Dacron graft
- Running 5-0 prolene for open distal anastomosis
- Attach Y’ed arterial cannula to grafts’ perfusion sidelimb; clamp graft, resume full flow through body and axillary cerebral
perfusion - Reimplant left subclavian artery with running 5-0 prolene, deair, move distal clamp proximal to this anastomosis
- Reimplant left common carotid artery, deair, move distal clamp proximal to this anastomosis
- Reimplant innominate artery, deair, move clamp proximal to innominate
- Remove innominate clamp (end selective antegrade cerebral perfusion)
- Begin rewarming (no greater than 2 oC temperature gradient)
- Clamp, cut, and oversew perfusion sidelimb of graft
- Check and repair anastomoses
- Graft to ascending aorta anastomosis with running 3-0 prolene
- Deair (pump down, clamp off)
- “Hot Shot” – Retrograde warm blood cardioplegia
- Place ventricular pacing wires
- Deep Trendelenburg position
- Remove crossclamp
- Check for hemostasis
- Wean from CPB
- Deair heart and aorta through root vent
- Remove LV vent
- Remove retrograde and venous cannulae
- Give protamine
- Clamp, divide, and oversew axillary graft
- Reinspect for bleeding, achieve hemostasis
- Pack chest
- Place chest tubes
- Place sternal wires
- Check wires for bleeding
- Close sternum
- Close skin
- Close axillary incision
Potential Complications and Pitfalls
- Stay midline during sternotomy
- Innominate vein injury
- Brachial plexus injury during axillary exposure
- Injury/delamination of arch vessels during dissection
- Failure to protect recurrent laryngeal nerves
- Tracheal injury during arch dissection
- Failure to insulate phrenic nerves from cold
- Innominate/axillary dissection or bleeding from perfusion limb graft
- Improper venous cannula positioning (hepatic vein, RV)
- Bleeding complications from venous cannulation
- Coronary sinus perforation
- Poor right heart protection (poor retrograde position)
- Air embolism from improper deairing of any arterial graft segment
- Poor LV venting
- Low outflow from perfusion graft
- Air embolism during open distal
- Unilateral cerebral perfusion secondary to unrecognized Circle of Willis obstruction
- Excessive or inadequate flow during selective antegrade cerebral perfusion
- Failure to recognize bleeding from distal anastomosis prior to proximal anastomosis
- Reperfusion injury from excessively fast rewarming
- Coronary air embolism during dearing
- Unrecognized bleeding from sternal wires
Template Dictation
Preoperative Diagnosis:
- [Expanding, symptomatic] Aortic Arch Aneurysm of [BLANK]cm
- [Connective tissue disorder]
Postoperative Diagnosis: Same (with appropriate adjustments)
Indications: There is limited data on isolated aortic arch aneurysms since they are often found in association with ascending
or descending aneurysms. Current guidelines closely follow the indications for ascending aneurysm repair. When deciding to
operate on the aortic arch, special consideration should be made to the increased perioperative risk of stroke and death in
comparison to isolated ascending or descending aortic aneurysm repair. Repair of the aortic arch is indicated when:
- Maximal arch diameter ≥5.0cm sporadically
- Aneurysm growth ≥0.5cm/year
- Maximal arch 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 arch diameter ≥4.2cm with a diagnosis of Loeys-Dietz syndrome
- Maximal arch diameter >4.5cm with family history of aortic dissection
- There is an aneurysm in the proximal descending thoracic aorta which will need future treatment with either TEVAR or
open surgery - Patients develop compressive symptoms (hoarseness, dysphagia, dyspnea, chest or back pain) with known aneurysm
i. Aneurysm rupture can present with chest pain, shoulder pain, and/or hemoptysis and warrants emergent surgical
intervention
Procedure(s) Performed:
- Total Aortic Arch Repair with deep hypothermic circulatory arrest and selective antegrade cerebral perfusion
- [±Axillary artery cutdown]
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [SEX] with [DURATION] history of [relevant connective disorder,
autoimmune disease, or infection] presented with an aortic arch aneurysm that was [size (±growth rate)].
Description of the Procedure: The patient was taken to the operating room on [DATE]. The patient’s identity and planned
procedure were verified, and the patient was placed on the operating room table in the supine position. General anesthesia was
induced. Neurologic monitoring was set up using [BLANK]. Bilateral radial arterial lines were placed, as was a right internal
jugular central venous line. A TEE probe was placed, and formal evaluation of the cardiac function was performed. The patient
was prepped and draped in the usual fashion, leaving both groins exposed. A time out was performed to confirm the correct
patient, site, and procedure. Prophylactic antibiotics were given.
A right axillary artery cutdown was performed taking care not to damage the trunks of the brachial plexus. The axillary artery
was isolated and proximal and distal control were obtained with silastic loops. IV Heparin (100 u/kg) was administered and
allowed to circulate for 3 minutes. An 8mm Dacron graft was sewed end-to-side onto the artery using 5-0 prolene in a running
fashion. The graft was deaired as the vascular clamps were removed.
Median sternotomy was then performed. The thymus was divided, and a pericardial well was created. The innominate vein
was encircled with a silastic, and the arch vessels were dissected free, taking care to protect the left recurrent laryngeal nerve
around the distal arch. The ascending aorta and arch were dissected free. [UNITS] of IV heparin were administered and allowed
to circulate. The right axillary conduit was cannulated, secured, and deaired.
A pursestring suture was placed in the right atrial appendage and a [SIZE] two stage venous cannula was placed into the IVC
through the right atrium and secured. The perfusion graft was deaired and connected to the CPB circuit. A small pursestring
was placed on the right atrium and a retrograde cardioplegia cannula was inserted into the coronary sinus. After confirmation
of proper ACT, CPB was initiated and systemic cooling to [BLANK]oC commenced. A left ventricular vent was placed
through the right superior pulmonary vein through a pursestring, and position was confirmed with TEE. Retrograde cold blood
cardioplegia was administered with the heart vented. The aortic crossclamp was placed.
As the patient was cooled, the diseased ascending aorta was resected up to the crossclamp. The healthy ascending aorta was
sized at [cm] and the appropriate Dacron graft opened. The proximal graft to aorta anastomosis was constructed using two
running 3-0 prolene sutures. When systemic hypothermia was achieved, mannitol, propofol, and hydrocortisone were
administered. CPB flow was stopped and the aortic crossclamp was removed. Flow was then increased to [10mL/kg/min]. The
innominate artery was clamped after backbleeding to deair. [Good retrograde flow was seen from the left common carotid
artery, and the artery was clamped]. [Poor retrograde flow was seen from the left common carotid artery, and a
pediatric retrograde cannula that was hooked to the arterial circuit was placed into its ostium. The artery was then
clamped]. The left subclavian artery [WAS/WAS NOT] clamped.
Carrel patches were fashioned out of each arch vessel. The aortic arch was resected distal to the left subclavian. Care was taken
to identify the left recurrent laryngeal nerve and gently retract it out of the way. The proximal descending aorta was sized at
[cm] and the appropriate multibranch arch graft was opened and trimmed. The distal graft to aorta anastomosis was constructed
with 3-0 prolene in a running fashion. The graft was deaired and clamped, and an aortic cannula was placed in the graft’s
perfusion sidelimb. Hemostasis was achieved. Normal CPB flow was reestablished, and circulatory arrest terminated.
Anastomoses were then constructed to the left subclavian, the left common carotid, and the innominate artery, in that order,
using 5-0 prolene in a running fashion. Hemostasis was assured and each anastomosis appropriately deaired. As each
anastomosis was completed, vascular clamps were removed restoring flow to the respective territory in a sequential matter.
After the innominate anastomosis was complete, the aortic crossclamp was placed on the proximal arch graft, and the perfusion
graft was doubly clamped and divided. It was oversewn with 3-0 prolene in two layers, obliterating dead space.
Systemic rewarming was then begun. The proximal graft to graft anastomosis was completed using 5-0 prolene in a running
fashion. The ascending aorta was deaired and a retrograde “Hot Shot” (warm blood cardioplegia) was administered. The
crossclamp was removed and ventricular pacing wires were placed. Normal sinus rhythm was restored, and the patient was
weaned from CPB. Ventilation was restarted. The heart was deaired through a Cooley needle in the ascending aorta. The
retrograde cardioplegia catheter and venous cannula were removed.
Protamine was administered. The axillary graft was clamped, divided, and oversewn with 5-0 prolene in two layers. All suture
lines were inspected, and hemostasis was achieved. [BLANK] chest tubes were placed. The sternum was then reapproximated
with eight #6 steel sutures. The wound was irrigated and closed using 0 vicryl for the periosteal fascia, 3-0 vicryl for the deep
dermal layer, and 4-0 monocryl for the subcuticular layer. The axillary incision was closed in two layers.
At the end of the case, all sponge and needle counts were correct. The patient was then transferred to the CVICU in stable but
critical condition. There were no complications.
CPB Time: [minutes]
Crossclamp Time: [minutes]
SACP Time: [minutes]
Lowest Temperature reached: [minutes]
Dr. [BLANK] was present and scrubbed for [BLANK] elements of the operation.
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.
When there is significant aortic valve insufficiency present, care must be taken to prevent ventricular distension after initiation
of CPB. In such cases, it is possible to crossclamp the ascending aorta earlier and arrest the heart while continuing to cool from
the innominate artery graft.
Minimizing the duration of circulatory arrest is important to minimize the risk of neurologic complications. However, bleeding
from the distal aortic anastomosis can be difficult to visualize and control after resuming systemic perfusion on CPB. To
improve hemostasis, the suture lines can be reinforced with a strip of bovine pericardium. The anastomoses should be
performed in such a way that the graft is placed inside the aorta and the bovine pericardial strip is on the outside. The sutures
should go around the bovine strip creating a sandwich of bovine pericardium, aorta, and then graft.
Multiple Choice Question(s)
A 39-year-old female previously diagnosed with Marfan syndrome is undergoing a total arch replacement for an arch aneurysm
that measured 5.2cm. The innominate artery was utilized for arterial cannulation and the right atrium for the venous
cannulation. The patient is being cooled in preparation for hypothermic circulatory arrest. When the bladder temperature
reaches 28oC, the heart begins to fibrillate. You notice that the heart rapidly distends despite a left ventricular vent. What is the
best next step?
A. Reposition the arterial cannula
B. Crossclamp the ascending aorta and give cardioplegia
C. Circulatory arrest and begin distal anastomosis
D. Add a second venous cannula in the SVC
E. Expose the femoral artery for cannulation
Answer: B. This patient likely has AI causing ventricular distention. In patients with Marfan syndrome, AI can occur due to
aortic annular dilation or myxomatous valvular degeneration. Special consideration should be made to evaluate for AI in
Marfan patients prior to cardiac surgery since the heart can distend while on CPB. In this case, the aortic valve is not competent,
which is causing the heart to distend despite a ventricular vent. The next best step would be to crossclamp the aorta and arrest
the heart. Retrograde cardioplegia or opening the aorta and giving antegrade cardioplegia via ostial cannulas are both acceptable
methods for arresting the heart.
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