3. 2 similar cases
both are young patients, from WA
prior dissecting Type A( ascending aorta)
aneurism, repaired in WA
complicated-leak around the graft, pseudo-
aneurysm formation along the aorta
otherwise stable
7. 3 different ways for open
thoracic aorta surgery
Total deep circulatory arrest-can have bad
neurological outcomes
Retrograde blood from (via SVC) to brain
while while ascending aorta is open
Antegrade, uninterrupted blood supply to
the brain throughout the surgery-very good
outcomes
8. Induction, very similar to
cardiac cases
Induction,with morphine, diazepam
Pre medication very similar to
cardiac cases
Large peripheral iv line.
9 Mac swan-sheath, VIP Pa catheter with
continuous cardiac output
4 lumen cvc
methlypredisolone at induction
9. 3 Art lines to monitor
circulation
to various parts of the
body
10. Stages of the surgery
Put patient on bypass
Isolate the inominate, left common carotid,
left subclavian in a sequential manner,
connect them to a graft to supply the brain-
antegrade perfusion
Hypothermia and circulatory arrest(for
organs below the aortic arch) when aorta is
opened
repair of aorta by EVITA graft
11. Putting patient on bypass
Slightly different from
usual
Retrograde perfusion
from arterial cannula in
right femoral artery
Venous drainage from
SVC
both are redo
sternotomies-access to
heart difficult
12. ONCE CPB IS
ESTABLISHED
The heart is ejecting less blood, making the
operating field more accessible
Body temp can be decreased for organ
protection
16. WHEN THAT
HAPPENED
then all three art-lines lost
their pressure readings
and colour doppler of the
aorta showed no flow into
subclavian artery
decrease venous drainage
into pump, allow heart to
fill and eject blood
normally
ventilate when heart
ejecting blood to lungs
19. Establishing cerebral
perfusion
The inominate, left
subclavian and right
brachiocephalic are
ligated and attached
to a graft in a
sequential manner
Arterial supply to the
brain via a side arm
from the graft
20. Brain perfusion always
maintained
The vessels are clamped and connected to
the graft one at a time
There are numerous collaterals when each
vessels is clamped
Once the graft is completely anastomosed,
the main pump supplies 10ml/kg of blood to
the brain
29. Next.....
Aortic cross clamp in distal arch
Cardioplegia ( custodial) from venous
cannula
deep hypothermia
then circulatory arrest below the arch
30. Followed by opening the
aorta
Then actual repair
two devises were used-EVITA stent, and
elephant trunk graft
31. EVITA stent
deployed by a guide wire
placed earlier in the
femoral artery
Can open up like an
umbrella and form a
watertight seal at the
junction of the
pseudoaneurysm
32. TOE used to confirm if
femoral guidewire is in the
the true lumen
33. Issues once aorta is
repaired
rewarming 35 C for 20 mins
coming of bypass
dealing with coagulopathy associated with
CPB and hypothermia
bleeding
This is a big topic. Dr McCall gave a very good talk on this at the recent Cardiac and Perfusion special interest group. Mine is just an introduction for others who havent done such cases yet.
A lot was going on in theatre and I found it a bit overwhelming. I will try to break down the whole process to smaller portions.
We did two cases in two weeks. My patients were both young men who had their aneurysms repaired in WA Asymptomatic, but complications were discovered during follow up
Perth is a very nice city This was one of the first questions I asked
The surgery has been done several times here, with good outcomes This is a recent publication The three main teams are experienced
Three methods of open aortic work The last method, the method we employ here, is the most physiological, and probably the one with the best outcome
the induction, and monitering are similar to many large cases 1g of methyprednisolone is given for spinal cord protection
2 radials and femoral art line are to monitor perfusion to various regions during different stages of the surgery
These are the 4 main stages of surgery To begin..... And the actual repair work is done
The vascular access for bypass is a bit different Blood flows in a retrograde flow, from machine to patient
the heart is ejecting little, or no blood
blood flow in a retrograde fashion is not normal the flow can become interrupted in a diseased, pathological aorta
if the retrograde flow puts pressure on a downward facing aortic fold, the fold will be pushed cranially, and become a flap
There might be communication between the true aortic lumen, and the false aneurysm lumen blood might flow in the false lumen, instead of along the true aortic lumen
we had that problem, when we lost pressure tracing in all 3 art lines by letting the heart eject, some of that retrograde flow may be reversed more importantly, the brain will get blood flow with so much going on, important to remember to ventilate when heart is ejecting blood
this is the after photo
you will notice this smaller centrifudge pump the mechanism is supposed to be better that of the roller pump
now for the next stage. there is not supposed to be any period of time related ischeamia the vessels are sequentially ligated and connected to the graft when the vessels that supplying the right are ligated, numerous collaterals from thyroid and facial arteries can supply the left-and vice versa
picture of the graft
the graft in vivo
this is our main roller pump supplying the head why roller pump for the head?the pump can work against high resistance i spent some time following the path of the lines to check my understanding
the oximeter help in 3 main ways warning us or critical events guiding pressures guiding flows
an interesting topic, next time
another method to reduce CmRO2
we kept the a BIS isoelectric
next, cross clamp was applied then the patient was cooled, to protect the spinal cord
