Central cannulation by Seldinger technique: a reliable method in ascending aorta and aortic arch replacement.

BACKGROUND: Extensive type A aortic dissections that involve peripheral great vessels can complicate the choice of a cannulation site for cardiopulmonary bypass. We started to employ direct cannulation of the true lumen on the concavity of the aortic arch by Seldinger technique and evaluated the efficacy of this access technique as an alternative arterial inflow target in aortic surgery. MATERIAL/METHODS: Twenty-four consecutive patients (mean age: 59±14 years) underwent type A aortic dissection repair using selective antegrade cerebral perfusion. Direct aortic cannulation was used in 14 cases, subclavian access in 6 patients, and femoral entry in 4 patients. Perioperative factors were evaluated to identify the reliability and eventual benefits of direct cannulation method at the aortic arch. RESULTS: There were no operative deaths and cumulative 30-day mortality rate was 25% (6). Permanent neurological deficits were not observed; in 1 patient transient changes occurred (4%). Time to reach circulatory arrest was the shortest in the direct access group, with mean 27±11 (CI: 20.6-33.3) min vs. 43±22 (28.0-78.0) min (p=0.058) and 32±8 (23.6-40.4) min (p=0.34) by femoral cannulation and subclavian entry, respectively. Direct arch cannulation resulted in the best renal function in the first 72 h after surgery and similar characteristics were observed in lactic acid levels. CONCLUSIONS: Ultrasound-guided direct cannulation on the concavity of the aortic arch using a Seldinger technique is a reliable method in dissection repairs. Prompt antegrade perfusion provides not only cerebral but also peripheral organ and tissue protection, which is an advantage in this high-risk group of patients.

Near-infrared spectroscopy-detected cerebral ischemia resolved by cannulation of an axillo-femoral graft during surgical repair of type A aortic dissection.

We report the case of a patient who experienced near-infrared spectroscopy (NIRS)-detected transient regional cerebral desaturation during cardiopulmonary bypass for an operation to replace the aortic arch. Prompt institution of additional flow through an axillo-femoral graft was associated with restoration of regional cerebral saturation. The aortic surgery had no neurologic complications. Promptness in detecting and restoring cerebral perfusion appeared crucial in avoiding prolonged cerebral ischemia and reducing the likelihood of adverse neurologic events.

High OPCAB surgical volume improves midterm event-free survival.

BACKGROUND: The aim of this study was to evaluate the midterm results of the initial phase of off-pump coronary artery bypass (OPCAB) surgery adoption in a single surgical unit, assessing the impact of procedural volume. METHODS: Study participants were 312 patients who underwent OPCAB during the period between August 2000 and January 2005 at S. Croce Hospital. Of these patients, 126 patients with an indication selected for comorbidities or 1-vessel disease underwent OPCAB performed by 4 low-volume surgeons, and 186 unselected patients underwent OPCAB performed by a single high-volume surgeon. RESULTS: OPCAB performed by low-volume surgeons was associated with less complete revascularization and less arterial conduit use. Early result analysis showed a low rate of in-hospital or 30-day adverse events. The 5-year survival was 0.88 (0.02 SE). OPCAB performance by a high-volume surgeon and complete revascularization were shown have a protective effect for midterm major adverse cardiac events (respectively, hazard ratio = 0.28, 95% confidence interval 0.11-0.74 and hazard ratio = 0.33, 95% confidence interval 0.15-0.73). CONCLUSION: Our study on the initial phase of OPCAB adoption suggests a benefit on midterm outcome from surgery performed by a high-volume surgeon.

Thermosensitive polymer use for shunt sealing in off-pump coronary artery bypass.

OBJECTIVE: : To check the efficacy of a reverse thermosensitive gel (poloxamer P407) for intracoronary shunt sealing in off-pump coronary artery bypass surgery to stop residual bleeding from the shunt and avoid the use of blowers. METHODS: : Nineteen coronary anastomoses were performed on five patients who underwent off-pump coronary artery bypass surgery. Intracoronary shunting was adopted in all procedures. All the shunts were sealed into the coronary lumen with the injection of a reverse thermosensitive gel. Before tying the sutures, a piece of ice was applied on the anastomotic sites to dissolve the gel. Bleeding from the coronary lumen was always checked after shunt removal. RESULTS: : Bleeding was stopped or reduced and anastomoses performed without blower use. In one case, bleeding started again after shunt manipulation, and the shunt sealing procedure needed to be repeated. No intraoperative surface electrocardiogram and regional motion changes were detected. All patients showed normal creatine kinase-MB (CK-MB) levels in the postoperative period. All patients were free from adverse cardiovascular events at 4 months from operation. CONCLUSIONS: : The use of a thermosensitive polymer for intracoronary shunt sealing was effective in controlling bleeding, eliminated the necessity for blower use, and was not associated to operative complications.