Central Partial Bypass Management Technique for Distal Arch Surgery

Circulatory arrest and left heart bypass are the most common approaches to manage perfusion during distal arch surgery. We report a novel perfusion technique utilized in the treatment of aneurysmal Komerrell's diverticulum (KD) and aberrant subclavian artery (ASA) that allows for a reliable conduct of perfusion. From 2016 to 2020, 12 adult patients with aneurysmal KD and ASA underwent repair of distal arch through lateral thoracotomy ipsilateral to the arch side using central partial bypass. Once the patients were fully heparinized the lower thoracic aorta and the right atrium were cannulated. The cannulas were connected to the cardiopulmonary bypass (CPB) circuit with an oxygenator. Partial bypass was initiated. Ventilation via anesthesia was continued as the mode of gas exchange to the upper body while the CPB circuit provided gas exchange to the lower body. In all patients, CPB was initiated allowing the patient to maintain a mean arterial pressure >60 mmHg in the femoral artery and a mean arterial pressure (MAP) >80 mmHg in the radial artery to allow adequate native ejection into the proximal circulation. The venous line was partially occluded to control the radial pressure. The aorta was cross clamped proximal and distal to the KD to isolate the aorta to be replaced. KD was excised in all patients having performed contralateral subclavian to carotid transposition previously. Once the aorta was reconstructed, clamps were released and the patients were weaned off CPB. All were extubated on the same day and there was no early mortality.