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Direct True Lumen Cannulation (“Samurai” Cannulation) for Acute Stanford Type A Aortic Dissection
Direct True Lumen Cannulation (“Samurai” Cannulation) for Acute Stanford Type A Aortic Dissection Tadashi Kitamura, MD, PhD, Masaki Nie, MD, PhD, Tetsuya Horai, MD, PhD, and Kagami Miyaji, MD, PhD Department of Cardiovascular Surgery, Kitasato University School of Medicine, Sagamihara, Japan
In operations for acute Stanford type A aortic dissection, several cannulation options are available for cardiopulmonary bypass arterial perfusion. These are femoral, axillary, Seldinger ascending aortic, transapical, and transatrial, each of which has advantages and drawbacks. We describe our surgical technique of direct true lumen
cannulation (“Samurai” cannulation), which represents an easy, safe, and practical option in operations for acute type A aortic dissection.
A
venous drainage are initiated. When the blood pressure drops to 30 mm Hg, which normally takes 10 to 15 seconds, the primary surgeon pulls up the aorta with his or her left hand, and both the adventitial and intimomedial walls of the dissected ascending aorta are incised simultaneously with large Metzenbaum scissors (Fig 1B). While blood wells up from the aorta, the perfusion line is run at a low flow rate and then directly and gently cannulated into the true lumen (Fig 1C). As blood gushes out of the aorta, the aortic tourniquets are snared; therefore, the aorta is deaired and cardiopulmonary bypass is established, followed by retrograde cardioplegia and systemic cooling. When the ascending false lumen is thrombosed, care should be taken not to drop any clots into the true lumen. A 24F cannula with a bump (APC024B; Edwards Lifesciences, Irvine, CA) is used for Samurai cannulation (Fig 2). The cannula is fixed on the sternal wound retractor (Fig 1D; Video).
ntegrade perfusion is generally preferable for cardiopulmonary bypass during cardiac operations. However, peripheral cannulation is often used in operations for acute Stanford type A aortic dissection. Peripheral cannulation can cause inadequate flow distribution between the true and false lumens, leading to organ malperfusion [1, 2]. Options for antegrade perfusion in acute type A dissection includes Seldinger aortic [3], left ventricular apical [4], and left atrial cannulation [5]; however, each of these techniques has its own advantages and drawbacks. In this article, we describe a simple technique of direct true lumen cannulation (“Samurai” cannulation) in operations for acute type A aortic dissection.
Technique After median sternotomy and pericardiotomy, dissection around the ascending aorta is commenced at the roof of the pulmonary artery bifurcation. Two umbilical tape tourniquets are placed around the aorta (Fig 1A). An epiaortic scan is then performed to examine the status of the ascending false lumen. After heparin is given, the patient is ventilated with pure oxygen for subsequent transient circulatory arrest. A left ventricular vent is inserted through the right upper pulmonary vein, a right atrial drainage cannula is inserted from the appendage, and then a retrograde cardioplegia cannula is inserted. In the head-down position, left ventricular venting and Accepted for publication Aug 4, 2017.
(Ann Thorac Surg 2017;104:e459–61) Ó 2017 by The Society of Thoracic Surgeons
Case Series From October 2013 to May 2016, we used the Samurai cannulation for acute Stanford type A aortic dissection in 49 patients. The mean age was 64 13 years; 28 were women. Nine patients had partial thrombosis of the ascending false lumen. True lumen cannulation was successful and sufficient perfusion flow was obtained in all patients. Collapse of the true lumen or new development of the false lumen of the descending aorta was not observed on transesophageal echocardiography in any patient. In 14 operations, the time from commencing venous drainage to securing the first aortic tourniquet
Presented at the Fifty-third Annual Meeting of The Society of Thoracic Surgeons, Houston, TX, Jan 21–25, 2017. Address correspondence to Dr Kitamura, Department of Cardiovascular Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa 252-0374, Japan; email: funcorogash@hotmail. com.
Ó 2017 by The Society of Thoracic Surgeons Published by Elsevier Inc.
The Video can be viewed in the online version of this article [http://dx.doi.org/10.1016/j.athoracsur.2017.08. 002] on http://www.annalsthoracicsurgery.org.
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2017.08.002
e460
HOW TO DO IT KITAMURA ET AL SAMURAI CANNULATION FOR ACUTE DISSECTION
Ann Thorac Surg 2017;104:e459–61
Fig 1. An intraoperative photograph showing (A) two tourniquets with umbilical tape placed around the ascending aorta, (B) incision of the dissected ascending aorta with large Metzenbaum scissors (note that the aorta is securely supported), (C) direct true lumen cannulation, and (D) fixation of the cannula onto the sternal retractor.
before cardiopulmonary bypass could be measured on the recorded video; mean time was 44 10 seconds (range: 28 to 65 seconds). Regional cerebral oxygen saturation was stable during cardiopulmonary bypass in all patients. Surgical procedures included four root replacements, 30 ascending replacements, two partial arch replacements with brachiocephalic and carotid reconstruction, 12 total arch replacements, and one David procedure plus total arch replacement. Sixteen operations (14 ascending replacements and two arch replacements) were performed by cardiovascular surgery trainees. Inhospital death occurred in 3 patients (6.1%). Three patients experienced disabling or fatal strokes (6.1%), one of whom recovered during late follow-up. There were no cannulation-related complications.
Seldinger cannulation can safely be performed at the undissected aspect of the ascending aortic wall [3], and it is therefore not suitable if there is a full- or nearcircumferential dissection (Fig 3). During left ventricular apical cannulation [4], positioning the heart can cause hemodynamic deterioration, and bleeding complications after decannulation can be a concern. In transatrial left ventricular cannulation [5], ventricular distention after hypothermic fibrillation and mitral regurgitation are of concern; this technique is also suboptimal if there is considerable aortic stenosis. In 2007, Jakob and colleagues [7] reported a case series in which direct true lumen cannulation with oblique aortic cross-clamping was used in operation for acute type A dissection. Conzelmann and colleagues [8] also reported direct true lumen cannulation using a Mersilene tourniquet (Ethicon, Sommerville, NJ) as a routine option.
Comment Femoral or axillary artery cannulation is often preferred in operations for acute Stanford type A aortic dissection [6], but malperfusion, dissection of the cannulation site, or plexus injury can be a concern [1, 2]. To achieve antegrade perfusion, other techniques have been reported.
Fig 2. Cannula with a bump used for Samurai cannulation.
Fig 3. Circumferential dissection of the ascending aorta.
Ann Thorac Surg 2017;104:e459–61
We use an arterial cannula with a bump and a double tourniquet technique to eliminate pericannular leaks. Double tourniquet technique also enables modest snaring. When securing the tourniquets, care must be taken not to tear the aortic wall by brutal snaring. Adding left ventricular venting substantially reduces the time needed for the pressure drop. According to previous reports, it takes 90 to 120 seconds [7, 8], whereas with our technique it normally takes only 30 to 60 seconds to establish full cardiopulmonary bypass. At present, there is uncertainty about the safety margin of anesthetized and fully heparinized normothermic circulatory arrest, especially in terms of cerebral circulation, and obviously the shortest possible arrest is desirable. In addition, the surgical procedures performed for acute type A dissection normally require hypothermic circulatory arrest with some form of brain protection, which is also associated with a certain risk of stroke. A large-sized study is required to prove the safety of this technique, but the rate of perioperative stroke in our study is comparable with reported rates: 6.1% versus 5.0% to 6.5% [4–6], and we believe that our technique is sufficiently safe in terms of stroke. Samurai cannulation is also advantageous for patients with morbid obesity, peripheral arterial disease, atherosclerotic descending aorta, and abdominal aortic aneurysm. The cannulated site is going to be replaced and no other “innocent” artery is going to be injured. Our technique is feasible in most cases with acute type A dissection, including those with circumferential dissection or a thrombosed ascending false lumen. In addition, in an
HOW TO DO IT KITAMURA ET AL SAMURAI CANNULATION FOR ACUTE DISSECTION
e461
emergency, rapid installation of cardiopulmonary bypass is feasible. In summary, Samurai cannulation is an easy, safe, and reasonable option for acute Stanford type A aortic dissection.
References 1. Paar GV, Manley NJ, Williams DR, Montesano RM. Obstruction of the true lumen during retrograde perfusion of type I aortic dissections. Ann Thorac Surg 1980;30:495–8. 2. Schachner T, Nagiller J, Zimmer A, Laufer G, Bonatti J. Technical problems and complications of axillary artery cannulation. Eur J Cardiothoracic Surg 2005;27:634–7. 3. Gobolos L, Philipp A, Foltan M, Wiebe K. Surgical management for Stanford type A aortic dissection: direct cannulation of real lumen at the level of the Botallo’s ligament by Seldinger technique. Interact Cardiovasc Thorac Surg 2008;7: 1107–9. 4. Sosnowski AW, Jutley RS, Masala N, Alexiou C, Swanevelder J. How I do it: transapical cannulation for acute type-A aortic dissection. J Cardiothorac Surg 2008;3:4. 5. Rahimi-Barfeh A, Grothusen C, Haneya A, et al. Transatrial cannulation of the left ventricle for acute type A aortic dissection: a 5-year experience. Ann Thorac Surg 2016;101:1753–8. 6. Gulbins H, Pritisanac A, Ennker J. Axillary versus femoral cannulation for aortic surgery: enough evidence for a general recommendation? Ann Thorac Surg 2007;83:1219–24. 7. Jakob H, Tsagakis K, Szabo A, Wiese I, Thielmann M, Herold U. Rapid and safe direct cannulation of the true lumen of the ascending aorta in acute type A aortic dissection. J Thorac Cardiovasc Surg 2007;134:244–5. 8. Conzelmann LO, Kayhan N, Mehlhorn U, Weigang E, Dahm M, Vahl CF. Reevaluation of direct true lumen cannulation in surgery for acute type A aortic dissection. Ann Thorac Surg 2009;87:1182–6.
In operations for acute Stanford type A aortic dissection, several cannulation options are available for cardiopulmonary bypass arterial perfusion. These are femoral, axillary, Seldinger ascending aortic, transapical, and transatrial, each of which has advantages and drawbacks. We describe our surgical technique of direct true lumen
cannulation (“Samurai” cannulation), which represents an easy, safe, and practical option in operations for acute type A aortic dissection.
A
venous drainage are initiated. When the blood pressure drops to 30 mm Hg, which normally takes 10 to 15 seconds, the primary surgeon pulls up the aorta with his or her left hand, and both the adventitial and intimomedial walls of the dissected ascending aorta are incised simultaneously with large Metzenbaum scissors (Fig 1B). While blood wells up from the aorta, the perfusion line is run at a low flow rate and then directly and gently cannulated into the true lumen (Fig 1C). As blood gushes out of the aorta, the aortic tourniquets are snared; therefore, the aorta is deaired and cardiopulmonary bypass is established, followed by retrograde cardioplegia and systemic cooling. When the ascending false lumen is thrombosed, care should be taken not to drop any clots into the true lumen. A 24F cannula with a bump (APC024B; Edwards Lifesciences, Irvine, CA) is used for Samurai cannulation (Fig 2). The cannula is fixed on the sternal wound retractor (Fig 1D; Video).
ntegrade perfusion is generally preferable for cardiopulmonary bypass during cardiac operations. However, peripheral cannulation is often used in operations for acute Stanford type A aortic dissection. Peripheral cannulation can cause inadequate flow distribution between the true and false lumens, leading to organ malperfusion [1, 2]. Options for antegrade perfusion in acute type A dissection includes Seldinger aortic [3], left ventricular apical [4], and left atrial cannulation [5]; however, each of these techniques has its own advantages and drawbacks. In this article, we describe a simple technique of direct true lumen cannulation (“Samurai” cannulation) in operations for acute type A aortic dissection.
Technique After median sternotomy and pericardiotomy, dissection around the ascending aorta is commenced at the roof of the pulmonary artery bifurcation. Two umbilical tape tourniquets are placed around the aorta (Fig 1A). An epiaortic scan is then performed to examine the status of the ascending false lumen. After heparin is given, the patient is ventilated with pure oxygen for subsequent transient circulatory arrest. A left ventricular vent is inserted through the right upper pulmonary vein, a right atrial drainage cannula is inserted from the appendage, and then a retrograde cardioplegia cannula is inserted. In the head-down position, left ventricular venting and Accepted for publication Aug 4, 2017.
(Ann Thorac Surg 2017;104:e459–61) Ó 2017 by The Society of Thoracic Surgeons
Case Series From October 2013 to May 2016, we used the Samurai cannulation for acute Stanford type A aortic dissection in 49 patients. The mean age was 64 13 years; 28 were women. Nine patients had partial thrombosis of the ascending false lumen. True lumen cannulation was successful and sufficient perfusion flow was obtained in all patients. Collapse of the true lumen or new development of the false lumen of the descending aorta was not observed on transesophageal echocardiography in any patient. In 14 operations, the time from commencing venous drainage to securing the first aortic tourniquet
Presented at the Fifty-third Annual Meeting of The Society of Thoracic Surgeons, Houston, TX, Jan 21–25, 2017. Address correspondence to Dr Kitamura, Department of Cardiovascular Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa 252-0374, Japan; email: funcorogash@hotmail. com.
Ó 2017 by The Society of Thoracic Surgeons Published by Elsevier Inc.
The Video can be viewed in the online version of this article [http://dx.doi.org/10.1016/j.athoracsur.2017.08. 002] on http://www.annalsthoracicsurgery.org.
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2017.08.002
e460
HOW TO DO IT KITAMURA ET AL SAMURAI CANNULATION FOR ACUTE DISSECTION
Ann Thorac Surg 2017;104:e459–61
Fig 1. An intraoperative photograph showing (A) two tourniquets with umbilical tape placed around the ascending aorta, (B) incision of the dissected ascending aorta with large Metzenbaum scissors (note that the aorta is securely supported), (C) direct true lumen cannulation, and (D) fixation of the cannula onto the sternal retractor.
before cardiopulmonary bypass could be measured on the recorded video; mean time was 44 10 seconds (range: 28 to 65 seconds). Regional cerebral oxygen saturation was stable during cardiopulmonary bypass in all patients. Surgical procedures included four root replacements, 30 ascending replacements, two partial arch replacements with brachiocephalic and carotid reconstruction, 12 total arch replacements, and one David procedure plus total arch replacement. Sixteen operations (14 ascending replacements and two arch replacements) were performed by cardiovascular surgery trainees. Inhospital death occurred in 3 patients (6.1%). Three patients experienced disabling or fatal strokes (6.1%), one of whom recovered during late follow-up. There were no cannulation-related complications.
Seldinger cannulation can safely be performed at the undissected aspect of the ascending aortic wall [3], and it is therefore not suitable if there is a full- or nearcircumferential dissection (Fig 3). During left ventricular apical cannulation [4], positioning the heart can cause hemodynamic deterioration, and bleeding complications after decannulation can be a concern. In transatrial left ventricular cannulation [5], ventricular distention after hypothermic fibrillation and mitral regurgitation are of concern; this technique is also suboptimal if there is considerable aortic stenosis. In 2007, Jakob and colleagues [7] reported a case series in which direct true lumen cannulation with oblique aortic cross-clamping was used in operation for acute type A dissection. Conzelmann and colleagues [8] also reported direct true lumen cannulation using a Mersilene tourniquet (Ethicon, Sommerville, NJ) as a routine option.
Comment Femoral or axillary artery cannulation is often preferred in operations for acute Stanford type A aortic dissection [6], but malperfusion, dissection of the cannulation site, or plexus injury can be a concern [1, 2]. To achieve antegrade perfusion, other techniques have been reported.
Fig 2. Cannula with a bump used for Samurai cannulation.
Fig 3. Circumferential dissection of the ascending aorta.
Ann Thorac Surg 2017;104:e459–61
We use an arterial cannula with a bump and a double tourniquet technique to eliminate pericannular leaks. Double tourniquet technique also enables modest snaring. When securing the tourniquets, care must be taken not to tear the aortic wall by brutal snaring. Adding left ventricular venting substantially reduces the time needed for the pressure drop. According to previous reports, it takes 90 to 120 seconds [7, 8], whereas with our technique it normally takes only 30 to 60 seconds to establish full cardiopulmonary bypass. At present, there is uncertainty about the safety margin of anesthetized and fully heparinized normothermic circulatory arrest, especially in terms of cerebral circulation, and obviously the shortest possible arrest is desirable. In addition, the surgical procedures performed for acute type A dissection normally require hypothermic circulatory arrest with some form of brain protection, which is also associated with a certain risk of stroke. A large-sized study is required to prove the safety of this technique, but the rate of perioperative stroke in our study is comparable with reported rates: 6.1% versus 5.0% to 6.5% [4–6], and we believe that our technique is sufficiently safe in terms of stroke. Samurai cannulation is also advantageous for patients with morbid obesity, peripheral arterial disease, atherosclerotic descending aorta, and abdominal aortic aneurysm. The cannulated site is going to be replaced and no other “innocent” artery is going to be injured. Our technique is feasible in most cases with acute type A dissection, including those with circumferential dissection or a thrombosed ascending false lumen. In addition, in an
HOW TO DO IT KITAMURA ET AL SAMURAI CANNULATION FOR ACUTE DISSECTION
e461
emergency, rapid installation of cardiopulmonary bypass is feasible. In summary, Samurai cannulation is an easy, safe, and reasonable option for acute Stanford type A aortic dissection.
References 1. Paar GV, Manley NJ, Williams DR, Montesano RM. Obstruction of the true lumen during retrograde perfusion of type I aortic dissections. Ann Thorac Surg 1980;30:495–8. 2. Schachner T, Nagiller J, Zimmer A, Laufer G, Bonatti J. Technical problems and complications of axillary artery cannulation. Eur J Cardiothoracic Surg 2005;27:634–7. 3. Gobolos L, Philipp A, Foltan M, Wiebe K. Surgical management for Stanford type A aortic dissection: direct cannulation of real lumen at the level of the Botallo’s ligament by Seldinger technique. Interact Cardiovasc Thorac Surg 2008;7: 1107–9. 4. Sosnowski AW, Jutley RS, Masala N, Alexiou C, Swanevelder J. How I do it: transapical cannulation for acute type-A aortic dissection. J Cardiothorac Surg 2008;3:4. 5. Rahimi-Barfeh A, Grothusen C, Haneya A, et al. Transatrial cannulation of the left ventricle for acute type A aortic dissection: a 5-year experience. Ann Thorac Surg 2016;101:1753–8. 6. Gulbins H, Pritisanac A, Ennker J. Axillary versus femoral cannulation for aortic surgery: enough evidence for a general recommendation? Ann Thorac Surg 2007;83:1219–24. 7. Jakob H, Tsagakis K, Szabo A, Wiese I, Thielmann M, Herold U. Rapid and safe direct cannulation of the true lumen of the ascending aorta in acute type A aortic dissection. J Thorac Cardiovasc Surg 2007;134:244–5. 8. Conzelmann LO, Kayhan N, Mehlhorn U, Weigang E, Dahm M, Vahl CF. Reevaluation of direct true lumen cannulation in surgery for acute type A aortic dissection. Ann Thorac Surg 2009;87:1182–6.