© 2014 Wiley Periodicals, Inc.
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A Method of Treating Patients with Acute Type A Aortic Dissection and Lower Extremity Malperfusion Athanasios Tsiouris, M.D., Gaetano Paone, M.D., Loay Kabbani, M.D., Judith Lin, M.D., Alexander D. Shepard, and Jeffrey A. Morgan, M.D. Division of Cardiothoracic Surgery, Henry Ford Hospital Heart and Vascular Institute, Detroit, Michigan ABSTRACT The management of an acute type A aortic dissection in the setting of peripheral vascular malperfusion is not well defined. Several institutions proceed with initial percutaneous intervention to restore end organ perfusion, followed by delayed operative repair of the type A dissection. This strategy is associated with high mortality rates from aortic rupture, myocardial infarction, and stroke. We describe a technique, where acute limb ischemia is concomitantly managed with the replacement of the ascending aorta/hemiarch or aortic arch. In addition to axillary artery cannulation, the ischemic lower extremity is perfused through a polytetrafluoroethylene (PTFE) graft, which is connected to the cardiopulmonary bypass (CPB) circuit. doi: 10.1111/jocs.12376 (J Card Surg 2014;29:526–528) Peripheral malperfusion syndrome can affect 15% to 40% of patients with type A aortic dissection with mortality rates as high as 90%2. Most surgeons support immediate aortic repair, which treats peripheral malperfusion by re-establishing flow in the true lumen. In cases where normal flow is not restored, additional vascular procedures are subsequently undertaken (endovascular, thrombectomy, bypass).1,2 Other institutions recommend initial peripheral interventions with selective arterial stenting or percutaneous fenestrations, followed by delayed repair of the proximal aorta.3 We describe a technique where acute limb ischemia is concomitantly managed with the replacement of the ascending aorta/hemiarch or aortic arch. In addition to axillary artery cannulation, the ischemic lower extremity is perfused through a polytetrafluoroethylene (PTFE) graft, which is connected to the cardiopulmonary bypass (CPB) circuit. SURGICAL TECHNIQUE Our health system’s Institutional Review Board (IRB) approved this study. Concomitantly with standard axillary artery and right atrial cannulation, the vascular
Conflict of interest: The authors acknowledge no conflict of interest in the submission. Address for correspondence: Athanasios Tsiouris, M.D., Department of General Surgery, 2799 West Grand Blvd., K-14 Detroit, MI 48202. Fax: þ1-313-916-2687; e-mail: [email protected]
surgeon performs a cutdown onto the femoral artery of the ischemic extremity. The patient is systemically heparinized, after which proximal control on the common femoral artery (CFA) and profunda femoris and distal control on the superficial femoral artery (SFA) is obtained with vessel loops and sequentially clamped. A longitudinal arteriotomy is performed on the CFA and a 8 mm PTFE graft (Atrium Medical, Hudson, NH, USA) is then sewn, end to side, using 5-0 Gore-Tex suture (Gore, Newark, DE, USA). If the dissection extends to the CFA, we proceed with a fenestration by performing a septostomy after which the graft is sewn. Care must be taken to carefully sew the graft onto the dissected CFA, which is usually thin if the dissection is anterior. The PTFE graft is then connected to the CPB machine, with both the right axillary and femoral arterial lines constituting the arterial circuit (Fig. 1). The same-size tubing on the CPB circuit is used for both the right axillary artery and the femoral artery. Flow rate is maintained at 2.4 L/min/m2. We then proceed with replacement of the ascending aorta and hemiarch/or total arch replacement, and resuspension of the aortic valve when necessary. The distal anastomosis is performed during deep hypothermic circulatory arrest and antegrade cerebral perfusion through the axillary line. After the heart is weaned off bypass, the femoral, popliteal, and pedal pulses are examined. If the femoral pulse is palpable or present on Doppler examination, the PTFE graft is transected with a vascular stapler and the groin incision is closed. If the femoral pulse is absent, a femoro-femoral bypass is performed after
J CARD SURG 2014;29:526–528
TSIOURIS, ET AL. TREATMENT OF EXTREMITY MALPERFUSION
527
Figure 1. Cardiopulmonary bypass circuit connected to the common femoral artery PTFE graft.
confirming the presence of a contralateral femoral pulse. An end-to-side anastomosis with a 8 mm PTFE graft is performed onto the contralateral femoral artery. This graft is then tunneled to the ischemic extremity and an end-to-end anastomosis is performed to the PTFE graft, which was used to perfuse the extremity during CPB. If a femoral pulse is present, and distal pulses are absent, then a selective angiogram is performed. Based on the angiographic findings (thrombosis vs. flow-limiting dissection flaps), additional endovascular procedures are undertaken (thrombectomy, stenting). Lower extremity fasciotomies are performed if pulses are absent after completing the type A dissection repair, and additional vascular interventions are required or if the onset of symptoms to institution of bypass time is >6 hours. RESULTS From December 2012 until July 2013, we have treated five patients with acute type A aortic dissection and associated lower extremity ischemia with the previously described technique. The mean age was 57 years (range 44 to 65 years); four patients were males and one patient was female. The left lower extremity was affected in three patients and the right in two patients and they all had Rutherford classification 2B acute ischemia (motor and sensory loss— immediately threatened/salvageable with immediate revascularization). Ascending aorta and hemiarch replacement with aortic valve resuspension was
performed in four patients, and one patient required complete arch reconstruction. Mean CPB time was 243 minutes (range 150 to 479 minutes), mean crossclamp time was 138 minutes (range 91 to 302 minutes), mean circulatory arrest time was 14 minutes (range 8 to 32 minutes), and mean antegrade cerebral perfusion time was 28 minutes (range 16 to 70 minutes). Two patients underwent femoro-femoral bypass, due to femoral pulse deficits after coming off bypass, and three patients had four-compartment fasciotomies of the affected lower extremity. All the patients who underwent fasciotomies ultimately had a functional extremity, without physical limitations. One patient died from multiorgan failure (MOF) on postoperative day 10, but had distal pulses on Doppler examination throughout his hospitalization. Limbs were salvaged in all patients and none required additional vascular procedures. No patients developed postoperative rhabdomyolysis. DISCUSSION The management of acute limb ischemia in patients with acute type A aortic dissection is not well defined. Most surgeons advocate that peripheral malperfusion will resolve with restoration of flow through the true lumen after performing an emergent repair of the proximal aorta.1 This is not universal, though, as approximately 50% of patients will require additional vascular procedures for persistent lower extremity ischemia.2 Other authors suggest that lower extremity
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TSIOURIS, ET AL. TREATMENT OF EXTREMITY MALPERFUSION
malperfusion in the setting of type A dissection is well tolerated in the short term, either from the presence of collateral flow (internal iliac, epigastric, deep circumflex arteries) or from the ameliorating anatomic features of the dissection flap, which allows intermittent or partial flow.4 In our case series, however, all patients had type IIB acute ischemia (absent pulse, sensory defect, and paralysis), which alone constitutes a surgical emergency. Skeletal muscle ischemia plays a significant role in postaortic surgery renal function. It is possible that early peripheral revascularization with our proposed technique could potentially reduce postoperative rhabdomyolysis, acute renal failure, and need for hemodialysis. Additionally, one should not ignore the inflammatory cascade and its potential complications, from prolonged muscle ischemia as a result of delayed peripheral revascularization.5 Other centers perform initial percutaneous interventions to restore end organ perfusion, followed by delayed repair of the type A dissection, after resolution of the reperfusion syndrome.6 This strategy, however, has been associated with higher mortality rates (50%) as a result of aortic rupture, myocardial infarction, or stroke prior to repair of the proximal dissection. Our technique allows early reperfusion of the ischemic extremity upon institution of CBP with concomitant emergent repair of the ascending aorta. If perfusion to the lower extremity is not restored after
J CARD SURG 2014;29:526–528
coming off bypass, the PTFE graft, which is connected to the arterial circuit, can also be used to perform a femoro-femoral bypasss. In our early experience, limb salvage rate is 100%. REFERENCES 1. Trimarchi S, Nienaber CA, Rampoldi V, et al: Contemporary results of surgery in acute type A aortic dissection: The International Registry of Acute Aortic Dissection experience. J Thorac Cardiovasc Surg 2005;129(1):112– 122. 2. Girardi LN, Krieger KH, Lee LY, et al: Management strategies for type A dissection complicated by peripheral vascular malperfusion. Ann Thorac Surg 2004;77(4):1309– 1314. 3. Deeb GM, Williams DM, Bolling SF, et al: Surgical delay for acute type A dissection with malperfusion. Ann Thorac Surg 1997;64(6):1669–1675. 4. Macchi C, Giannelli F, Cecchi F, et al: Collateral circulation in occlusion of lower limbs arteries: An anatomical study and statistical research in 35 old subjects. Ital J Anat Embryol 1996;101(2):89–96. 5. Miller CC III, Villa MA, Achouh P, et al: Intraoperative skeletal muscle ischemia contributes to risk of renal dysfunction following thoracoabdominal aortic repair. Eur J Cardiothorac Surg 2008;33(4):691–694. 6. Patel HJ, Williams DM, Dasika NL, et al: Operative delay for peripheral malperfusion syndrome in acute type A aortic dissection: A long-term analysis. J Thorac Cardiovasc Surg. 2008;135(6):1288–1295.
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SURGICAL TECHNIQUE ___________________________________________________________
A Method of Treating Patients with Acute Type A Aortic Dissection and Lower Extremity Malperfusion Athanasios Tsiouris, M.D., Gaetano Paone, M.D., Loay Kabbani, M.D., Judith Lin, M.D., Alexander D. Shepard, and Jeffrey A. Morgan, M.D. Division of Cardiothoracic Surgery, Henry Ford Hospital Heart and Vascular Institute, Detroit, Michigan ABSTRACT The management of an acute type A aortic dissection in the setting of peripheral vascular malperfusion is not well defined. Several institutions proceed with initial percutaneous intervention to restore end organ perfusion, followed by delayed operative repair of the type A dissection. This strategy is associated with high mortality rates from aortic rupture, myocardial infarction, and stroke. We describe a technique, where acute limb ischemia is concomitantly managed with the replacement of the ascending aorta/hemiarch or aortic arch. In addition to axillary artery cannulation, the ischemic lower extremity is perfused through a polytetrafluoroethylene (PTFE) graft, which is connected to the cardiopulmonary bypass (CPB) circuit. doi: 10.1111/jocs.12376 (J Card Surg 2014;29:526–528) Peripheral malperfusion syndrome can affect 15% to 40% of patients with type A aortic dissection with mortality rates as high as 90%2. Most surgeons support immediate aortic repair, which treats peripheral malperfusion by re-establishing flow in the true lumen. In cases where normal flow is not restored, additional vascular procedures are subsequently undertaken (endovascular, thrombectomy, bypass).1,2 Other institutions recommend initial peripheral interventions with selective arterial stenting or percutaneous fenestrations, followed by delayed repair of the proximal aorta.3 We describe a technique where acute limb ischemia is concomitantly managed with the replacement of the ascending aorta/hemiarch or aortic arch. In addition to axillary artery cannulation, the ischemic lower extremity is perfused through a polytetrafluoroethylene (PTFE) graft, which is connected to the cardiopulmonary bypass (CPB) circuit. SURGICAL TECHNIQUE Our health system’s Institutional Review Board (IRB) approved this study. Concomitantly with standard axillary artery and right atrial cannulation, the vascular
Conflict of interest: The authors acknowledge no conflict of interest in the submission. Address for correspondence: Athanasios Tsiouris, M.D., Department of General Surgery, 2799 West Grand Blvd., K-14 Detroit, MI 48202. Fax: þ1-313-916-2687; e-mail: [email protected]
surgeon performs a cutdown onto the femoral artery of the ischemic extremity. The patient is systemically heparinized, after which proximal control on the common femoral artery (CFA) and profunda femoris and distal control on the superficial femoral artery (SFA) is obtained with vessel loops and sequentially clamped. A longitudinal arteriotomy is performed on the CFA and a 8 mm PTFE graft (Atrium Medical, Hudson, NH, USA) is then sewn, end to side, using 5-0 Gore-Tex suture (Gore, Newark, DE, USA). If the dissection extends to the CFA, we proceed with a fenestration by performing a septostomy after which the graft is sewn. Care must be taken to carefully sew the graft onto the dissected CFA, which is usually thin if the dissection is anterior. The PTFE graft is then connected to the CPB machine, with both the right axillary and femoral arterial lines constituting the arterial circuit (Fig. 1). The same-size tubing on the CPB circuit is used for both the right axillary artery and the femoral artery. Flow rate is maintained at 2.4 L/min/m2. We then proceed with replacement of the ascending aorta and hemiarch/or total arch replacement, and resuspension of the aortic valve when necessary. The distal anastomosis is performed during deep hypothermic circulatory arrest and antegrade cerebral perfusion through the axillary line. After the heart is weaned off bypass, the femoral, popliteal, and pedal pulses are examined. If the femoral pulse is palpable or present on Doppler examination, the PTFE graft is transected with a vascular stapler and the groin incision is closed. If the femoral pulse is absent, a femoro-femoral bypass is performed after
J CARD SURG 2014;29:526–528
TSIOURIS, ET AL. TREATMENT OF EXTREMITY MALPERFUSION
527
Figure 1. Cardiopulmonary bypass circuit connected to the common femoral artery PTFE graft.
confirming the presence of a contralateral femoral pulse. An end-to-side anastomosis with a 8 mm PTFE graft is performed onto the contralateral femoral artery. This graft is then tunneled to the ischemic extremity and an end-to-end anastomosis is performed to the PTFE graft, which was used to perfuse the extremity during CPB. If a femoral pulse is present, and distal pulses are absent, then a selective angiogram is performed. Based on the angiographic findings (thrombosis vs. flow-limiting dissection flaps), additional endovascular procedures are undertaken (thrombectomy, stenting). Lower extremity fasciotomies are performed if pulses are absent after completing the type A dissection repair, and additional vascular interventions are required or if the onset of symptoms to institution of bypass time is >6 hours. RESULTS From December 2012 until July 2013, we have treated five patients with acute type A aortic dissection and associated lower extremity ischemia with the previously described technique. The mean age was 57 years (range 44 to 65 years); four patients were males and one patient was female. The left lower extremity was affected in three patients and the right in two patients and they all had Rutherford classification 2B acute ischemia (motor and sensory loss— immediately threatened/salvageable with immediate revascularization). Ascending aorta and hemiarch replacement with aortic valve resuspension was
performed in four patients, and one patient required complete arch reconstruction. Mean CPB time was 243 minutes (range 150 to 479 minutes), mean crossclamp time was 138 minutes (range 91 to 302 minutes), mean circulatory arrest time was 14 minutes (range 8 to 32 minutes), and mean antegrade cerebral perfusion time was 28 minutes (range 16 to 70 minutes). Two patients underwent femoro-femoral bypass, due to femoral pulse deficits after coming off bypass, and three patients had four-compartment fasciotomies of the affected lower extremity. All the patients who underwent fasciotomies ultimately had a functional extremity, without physical limitations. One patient died from multiorgan failure (MOF) on postoperative day 10, but had distal pulses on Doppler examination throughout his hospitalization. Limbs were salvaged in all patients and none required additional vascular procedures. No patients developed postoperative rhabdomyolysis. DISCUSSION The management of acute limb ischemia in patients with acute type A aortic dissection is not well defined. Most surgeons advocate that peripheral malperfusion will resolve with restoration of flow through the true lumen after performing an emergent repair of the proximal aorta.1 This is not universal, though, as approximately 50% of patients will require additional vascular procedures for persistent lower extremity ischemia.2 Other authors suggest that lower extremity
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TSIOURIS, ET AL. TREATMENT OF EXTREMITY MALPERFUSION
malperfusion in the setting of type A dissection is well tolerated in the short term, either from the presence of collateral flow (internal iliac, epigastric, deep circumflex arteries) or from the ameliorating anatomic features of the dissection flap, which allows intermittent or partial flow.4 In our case series, however, all patients had type IIB acute ischemia (absent pulse, sensory defect, and paralysis), which alone constitutes a surgical emergency. Skeletal muscle ischemia plays a significant role in postaortic surgery renal function. It is possible that early peripheral revascularization with our proposed technique could potentially reduce postoperative rhabdomyolysis, acute renal failure, and need for hemodialysis. Additionally, one should not ignore the inflammatory cascade and its potential complications, from prolonged muscle ischemia as a result of delayed peripheral revascularization.5 Other centers perform initial percutaneous interventions to restore end organ perfusion, followed by delayed repair of the type A dissection, after resolution of the reperfusion syndrome.6 This strategy, however, has been associated with higher mortality rates (50%) as a result of aortic rupture, myocardial infarction, or stroke prior to repair of the proximal dissection. Our technique allows early reperfusion of the ischemic extremity upon institution of CBP with concomitant emergent repair of the ascending aorta. If perfusion to the lower extremity is not restored after
J CARD SURG 2014;29:526–528
coming off bypass, the PTFE graft, which is connected to the arterial circuit, can also be used to perform a femoro-femoral bypasss. In our early experience, limb salvage rate is 100%. REFERENCES 1. Trimarchi S, Nienaber CA, Rampoldi V, et al: Contemporary results of surgery in acute type A aortic dissection: The International Registry of Acute Aortic Dissection experience. J Thorac Cardiovasc Surg 2005;129(1):112– 122. 2. Girardi LN, Krieger KH, Lee LY, et al: Management strategies for type A dissection complicated by peripheral vascular malperfusion. Ann Thorac Surg 2004;77(4):1309– 1314. 3. Deeb GM, Williams DM, Bolling SF, et al: Surgical delay for acute type A dissection with malperfusion. Ann Thorac Surg 1997;64(6):1669–1675. 4. Macchi C, Giannelli F, Cecchi F, et al: Collateral circulation in occlusion of lower limbs arteries: An anatomical study and statistical research in 35 old subjects. Ital J Anat Embryol 1996;101(2):89–96. 5. Miller CC III, Villa MA, Achouh P, et al: Intraoperative skeletal muscle ischemia contributes to risk of renal dysfunction following thoracoabdominal aortic repair. Eur J Cardiothorac Surg 2008;33(4):691–694. 6. Patel HJ, Williams DM, Dasika NL, et al: Operative delay for peripheral malperfusion syndrome in acute type A aortic dissection: A long-term analysis. J Thorac Cardiovasc Surg. 2008;135(6):1288–1295.
