Central Cannulation Strategy Via Left Thoracotomy in the Treatment of Chronic or Residual Type B Dissection Extent I Thoracoabdominal + Distal Aortic Arch Aneurysms. Prashanth Vallabhajosyula, MD, Tyler Wallen, BA, Joseph Bavaria, MD, Caroline Komlo, BS, Alberto Pochettino, MD
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Central Cannulation Strategy Via Left Thoracotomy in the Treatment of Chronic or Residual Type B Dissection Extent I Thoracoabdominal + Distal Aortic Arch Aneurysms Prashanth Vallabhajosyula, MD, Tyler Wallen, BA, Joseph Bavaria, MD, Caroline Komlo, BS, Alberto Pochettino, MD The University of Pennsylvania Health System Philadelphia, PA
Background • Extent I repair of thoracoabdominal (TAAA) aneurysms with chronic Type-B dissection is a technically complex operation typically requiring circulatory arrest for open proximal anastomosis in reverse hemiarch • Standard methods of circulation management include femoral arterial-femoral venous, femoral arterial-right/left atrial cannulation • We describe a novel central cannulation strategy performed entirely through the left chest for treatment of extent 1 TAAA with chronic type B dissection.
Central Cannulation Strategy • Arterial cannulation: direct cannulation of the true lumen of the descending thoracic aorta using seldinger technique under transesophageal echocardiography guidance (18-20 Fr cannula) • Venous cannulation: open pericardial sack for posterior exposure of RA-IVC junction (32-36 Fr right angle, single stage cannula) • Placement of left ventricular vent via left inferior pulmonary vein
Purpose • To evaluate the outcomes of TAAA extent I repairs for aneurysmal chronic type B dissection comparing central versus femoral cannulation.
Methods • From 2000-20111, retrospective review of all aneurysmal TAAA with chronic type B dissections that underwent open operative repair at the Hospital of the University of Pennsylvania • Extent I repairs were divided into 2 groups: central cannulation group versus femoral cannulation group • Primary endpoints were death, paraplegia and stroke • Secondary endpoints were reoperation for bleeding, MI, tracheostomy rate and length of stay (LOS) • Early and midterm results are reported
Methods Chronic Type B TAA Repair (N=108) TEVAR (N=20) Open Extent II/III Repair (N=29) Open Extent I Repair (N=59) Central Cannulation (N=28) Femoral/standard Cannulation (N=31)
Follow-Up Central Cannulation: 3.61 +/-2.07 years Mean Follow-Up Femoral Cannulation: 5.63+/-2.64 years Central Cannulation: 3.08 years Median Follow-Up Femoral Cannulation: 6.22 years 1 year mortality: 0% (N=0) Central Cannulation 3 year mortality: 10.5% (N=4) 1 year mortality: 12.9% (N=4) Femoral Cannulation 3 year mortality: 16.7% (N=5) *Mortality difference between the two groups was non-significant.
Conclusion • Central cannulation strategy via the left thoracotomy incision in the treatment of extent I TAAA with chronic type B dissection is a safe approach, with equivalent early and midterm outcomes compared to more traditional cannulation techniques. • This technique enables the entire extent type I repair to be performed via the left chest • It may have applicability in patients with prohibitive ileofemoral disease or those with difficult groin exposure due to previous operations or radiation