Discussion
Complications associated with aortic cannulation can be potentially catastrophic.2,3 In the event of aortic injury, prompt recognition and management are critical. Multiple aortic cannulations must also be avoided if the aorta has been partially denuded or weakened.4,5
Repair can range from a small bovine or pericardial patch to total ascending or arch replacement with prosthetic graft as dictated by the degree of injury. For large tears or dissections, hypothermic circulatory arrest is often needed as an adjunct.
Our technique blends both the patch and graft approaches, and it is novel in that—rather than utilizing a circumferential Dacron tube graft with a sidearm—we instead merely cut out the side-arm (with a generous skirt) to serve as the patch. Our technique (1) allows for an extended patch repair of the aorta rather than full aortic replacement (2) consequently shortens the time needed for repair and/or circulatory arrest and (3) simultaneously eliminates the need for a second arterial cannulation site on already potentially comprised aorta. After the repair was complete, the side-arm patch served as arterial inflow for the bypass circuit. Given the small stature of this patient, the femoral artery cannula was most likely providing little perfusion to her distal limb. By converting to a central arterial inflow site, the patients leg experienced greatly reduced ischemic time.
Potential disadvantages of this technique include the cost and wasted material associated with off-label use of the commercially available aortic graft. Additionally, our technique should only be employed for aortic injuries without an extensive proximal or distal dissection, such that the injured aorta can clearly be distinguished and excised to provide a clean border of healthy aorta for anastomosis. Liberal excision of the damaged aorta is critical for both confirming the absence of dissection and ensuring an anastomosis that will tolerate arterial inflow; longer-term efficacy or safety could otherwise be compromised. The skirt size can be modified to accommodate larger excisions while still avoiding a circumferential repair.
In conclusion, this strategy for managing aortic injuries is an easily reproducible technique or “trick” to simplify the management of a potential aortic cannulation disaster.