CARDIOVASCULAR JOURNAL OF AFRICA • Volume 25, No 1, January/February 2014
e4
AFRICA
Our patient had not undergone either aortic or cardiac surgery
before. He had been diagnosed with type II aortic dissection three
years earlier and had rejected surgical intervention. The patient
had not had any potentially life-threatening complications due
to the ascending aortic dissection during the time following the
initial diagnosis of the dissection. The dissecting aortic section
had become chronic over the years and the aortic segment had
become an aneurysmatic event.
However, the patient had developed aortic calcification
and the clinical picture became advanced-stage aortic stenosis
because of a bicuspid aortic valve. Moreover, during his recent
hospitalisation because of the chronic dissecting aortic aneurysm
and calcified bicuspid aortic valve, coronary artery disease
requiring surgical intervention was also identified.
The surgical method is determined by the extent of the lesion.
Bentall operations, total arch replacement, and ascending aortic
replacement can be performed.
3-5
During surgical intervention
on the ascending aorta itself, its branches, or on aortic valves,
cerebral protection can be achieved using techniques such
as deep hypothermic circulatory arrest, retrograde cerebral
perfusion, or antegrade selective cerebral perfusion, individually
or in combination. In our patient, we ensured both systemic
and cerebral perfusion using the open aortic technique under
moderate hypothermia (30°C), performing direct innominate and
femoral artery cannulation.
During the open technique, the distal aortic graft was sutured,
maintaining cerebral perfusion via the innominate artery only.
Then the cross clamp was positioned over the sutured graft and
cardiopulmonary bypass was continued through both innominate
and femoral arterial routes. Both aortic valve replacement and
proximal graft suturing were done and the cross clamp was
removed. A coronary bypass procedure was then performed on
the beating heart.
Conclusion
When our patient underwent a cardiopulmonary bypass, both
innominate and femoral arterial perfusions were sufficient to
sustain a systemic volume flow. Cerebral perfusion via the
innominate artery only during the open aortic technique, and both
innominate and femoral perfusions after cross-clamping sufficed
to provide systemic protection and organ perfusion in our patient.
The technique used for brain protection with normothermic
direct innominate artery cannulation without circulatory arrest
in the management of chronic aneurysmatic aortic dissection
indicated that it is a safe and a suitable alternative to other
procedures, such as DHTCA and/or antegrade or retrograde
cerebral perfusion.
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