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Safe aortic arch clamping in patients with patent internal thoracic artery grafts
Marisa M Jones1, Mehmet Akay, Daniel Murariu
1Division of Cardiovascular Surgery, the Texas Heart Institute at St. Luke's Episcopal Hospital, and Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas 77030, USA.
Insights
For patients with prior coronary artery bypass, a left carotid-subclavian bypass can prevent cardiac complications during aortic aneurysm repair. This alternative avoids hypothermic circulatory arrest and cardiopulmonary bypass.
Area of Science:
- Cardiovascular Surgery
- Thoracic Aortic Aneurysm Repair
- Vascular Surgery
Background:
- Coronary artery bypass grafting (CABG) using the left internal thoracic artery (LITA) is common.
- Aortic clamping during descending thoracic and thoracoabdominal aortic aneurysm (TAAA) repair can cause cardiac complications in LITA-CABG patients.
- Hypothermic circulatory arrest (HCA) is a current strategy to avoid aortic clamping in these cases.
Purpose of the Study:
- To present an alternative strategy to HCA for TAAA repair in LITA-CABG patients.
- To demonstrate the safety and efficacy of left carotid-subclavian bypass prior to aortic cross-clamping.
Main Methods:
- A left carotid-subclavian bypass was performed before aneurysm repair.
- This allowed for aortic cross-clamping proximal to the left subclavian artery.
- The technique avoided the need for cardiopulmonary bypass and HCA.
Main Results:
- The described technique successfully facilitated aortic cross-clamping proximal to the left subclavian artery.
- Major intraoperative cardiac complications were prevented.
- The procedure avoided the need for cardiopulmonary bypass and HCA.
Conclusions:
- Left carotid-subclavian bypass is a viable alternative to HCA for TAAA repair in LITA-CABG patients.
- This approach mitigates the risk of cardiac complications associated with aortic clamping.
- The technique offers a potentially safer and more efficient surgical option.
Abstract:
In patients who have undergone coronary artery bypass with a left internal thoracic artery graft, clamping the aorta proximal to the left subclavian artery during descending thoracic and thoracoabdominal aortic aneurysm repair can precipitate major cardiac complications. Many centers use hypothermic circulatory arrest to obviate the need for aortic clamping in these cases. Herein, we describe the successful application of an alternative approach to this problem: performing left carotid-subclavian bypass before aneurysm repair. This technique allows aortic cross-clamping proximal to the left subclavian artery, prevents major intraoperative cardiac complications, and avoids cardiopulmonary bypass and hypothermic circulatory arrest.
