Transpericardial inferior vena caval cannulation in thoracic aorta operations

Transpericardial Inferior Vena Caval Cannulation in Thoracic Aorta Operations Eugenio Neri, MD, Dominique Maiza, MD, Olivier Coffin, MD, and Massimo Massetti, MD Thoracic and Cardiovascular Department, University Hospital, Caen, France

Surgical treatment of thoracic aneurysms is frequently performed with the aid of partial cardiopulmonary bypass. When profound hypothermia and circulatory arrest are employed, inadequate venous drainage may represent a major problem. We herein describe a technique of inferior vena caval cannulation that allows steady performance when high p u m p flows are imposed. (Ann Thorac Surg 1996;62:1208-9)

thoracotomy and thoracoabdominal inp osterolateral cisions are the exposures of choice for the treatment of thoracic aorta aneurysm. The replacement of segments of the descending aorta through these exposures is frequently performed with the aid of partial cardiopulmonary bypass. The adjunct of profound hypothermia and circulatory arrest may offer some advantages in terms of hemodynamic stability, technical flexibility, spinal cord and viscera protection, and operative comfort [1-5]; on the other hand, it requires high p u m p flows and optimal venous drainage. Venous drainage of cardiopulmonary bypass is classically obtained by a cannula introduced in the right atrium through the femoral vein. Inadequate venous drainage (because of the small caliber of the cannulas), difficulty in getting over the iliocaval junction or reaching right atrium (because of a collapsed inferior vena cava), and interruption of limb venous flow are some of the c o m m o n problems encountered with this technique [4, 5]. Percutaneous wire-guided insertion techniques and new design cannulas are now available. They obviate some of the drawbacks of femoral vein cannulation, but they do not always guarantee adequate performance. Alternative venous cannulation sites have been proposed, to allow high p u m p outputs [41. Right ventricular cannulation through the pulmonary trunk allows good venous return [3, 5] but has some disadvantages [4]. In case of a large aneurysm it can be difficult to achieve optimal pulmonary artery exposure; furthermore, this kind of cannulation exposes the patient to the risk of pulmonary artery and pulmonary valve damage, and to pulmonaD, artery stenosis after removal of cannulas. This

kind of cannulation also does not offer optimal operative comfort, because the venous cannula is across the operative field during the procedure. Left external iliac vein [2] and left renal vein cannulation [4] are additional options: the former imposes an additional left lower quadrant incision for a retroperitoneal approach, and the latter is feasible only in the case of thoracoabdominal exposure. We describe herein the technique of transpericardial inferior vena caval cannulation that we use in thoracic aorta operations. It is performed through posterolateral thoracotomy and thoracoabdominal incisions with the aid of cardiopulmonary bypass, profound hypothermia, and circulatory arrest. Technique If a left posterolateral thoracotomy approach is chosen, this is made through the fifth or sixth intercostal space, the left lung is collapsed, and the pericardium is incised vertically, posterior to the left phrenic nerve. The incision is enlarged dorsally along the diaphragmatic reflection of the pericardium. The pulmonary ligament is divided, and the preesophageal pericardium and the pericardial reflection of the inferior vena cava are cut (Fig 1). Additional mobilization can be obtained by liberating the inferior vena cava across the diaphragm. Care must he paid not to open the right pleura, because a large quantity of blood can gather in the right pleural cavity during the procedure.

~

L.PHRENIC N,

Accepted for publication June 10, 1996. Address reprint requests to Dr Neri, Thoracic and Cardiovascular Department, University Hospital, Avenue Cote de Nacre 14033, Caen, France.

© 1996 by The Society of Thoracic Surgeons Published by Elsevier Science [nc

Fig I. lntrathoracic path toward ir(ferior vena cava flVC). (ESOPH. esopha,qus; L. h'fi; N nerve.)

0003-49751961515.00 PII S0003-4975(96)00599-1

Ann Thorac Surg 1996;62:1208-9

HOW TO DO IT NERIET AL TRANSPERICARD1ALIVC CANNULATION

1209

sutures inside the area of the pursestring is to prevent any laceration of the inferior vena cava caused by the stay sutures from b e c o m i n g a major problem at d e c a n n u l a tion.

Comment

/

'i

Pm IVC

Fig 2. lntnwperativc aspect of infi, rior vena caval exposure through h,ft tlwracotomy. (CS = coronary sinus; D - diaphragm; E = esophagus; IVC - inferior vena tara; L lung; PR - pericardial reflection.)

The anterior free edge of the pericardium is s u s p e n d e d with a stay suture, a n d the heart is gently pulled cranially while the diaphragm is lowered. This exposes the inferior vena cava, a n d a 3-0 Ticron pursestring suture is performed, large enough to enable the insertion of a 32F to 36F right-angled c a n n u l a into the right atrium (Fig 2). Some space must be left b e t w e e n the pursestring suture and the right atrium to avoid lesions of the coronary sinus. To facilitate the insertion of the cannula, two fine m o n o f i l a m e n t stay sutures can be placed inside the pursestring area, allowing e n o u g h counterpulsion for the insertion of the cannula. They are very useful w h e n the inferior vena cava is small or collapsed, avoiding traction on the pursestring. The rationale for placing the stay

Since 1993 we have performed transpericardial inferior vena caval c a n n u l a t i o n in 23 operations on the descending aorta for extensive aneurysm. In all 23 patients transpericardial inferior vena caval c a n n u l a t i o n was easy to perform a n d no complication was encountered. In 2 cases it was not possible to employ this technique because of previous sternotomy and s u b s e q u e n t pericardial adhesions. The proposed technique represent a viable alternative to the traditional techniques, allows excellent v e n o u s drainage, and, in spite of its d e m a n d i n g appearance, is not difficult to perform. Nevertheless, the extensive posterior pericardial o p e n i n g a n d the depth a n d limited area of the operative field require a thorough knowledge of the region, cautious dissection, and attentive identification of the structures. Transpericardial inferior vena caval c a n n u l a t i o n is particularly indicated w h e n p r o f o u n d hypothermia a n d circulatory arrest are considered for replacement of segments of the descending aorta.

References 1. Livesay JJ, Cooley DA, Ventemiglia RA, et al. Surgical experience in descending thoracic aneurysmectomy with or without adjuncts to avoid ischemia. Ann Thorac Surg 1985;39: 37- 46. 2. Carlson DE, Karp RB, Kouchoukos NT. Surgical treatment of aneurysms of the descending thoracic aorta: an analysis of 85 patients. Ann Thorac Surg 1983;35:58-69. 3. Kouchoukos NT, Wareing TH, Izumoto H, Clausing W, Abboud N. Elective hypothermic cardiopulmonary bypass and circulatory arrest for spinal cord protection during operations on the thoracoabdominal aorta. J Thorac Cardiovasc Surg 1990;99:659-64. 4. Kieffer E, Godet G, Koskas F, et al. Chirurgie des anevrysmes de l'aorte thoracique descendante et thoraco-abdominale: techniques et indications de la perfusion aortique distale. In: Fichelle JM, ed. Techniques et strategie en chirurgie vasculaire. Paris: AERCV, 1991:109-38. 5. Kazui T, Komatsu S, Yokoyama H. Surgical treatment of aneurysms of the descending thoracic aorta with the aid of partial cardiopulmonary bypass: an analysis of 95 patients. Ann Thorac Surg 1987;43:622-7.