A 37-year-old man with a bicuspid aortic valve had previously undergone aortic valve replacement and ascending aortic replacement. Persistent postoperative symptoms were followed by the development of a presternal pulsatile collection. Computed tomography (CT) imaging demonstrated an enhancing retrosternal/anterior mediastinal pseudoaneurysm associated with the ascending aortic tube graft, with blood surrounding the aorta and no residual pericardial hematoma.
The major operative hazard was repeat median sternotomy in the presence of a pseudoaneurysm immediately deep to the sternum. Entry into the pseudoaneurysm before establishing control could result in catastrophic hemorrhage and air embolism. The authors therefore used an operative strategy based on femoral cardiopulmonary bypass combined with continuous antegrade cerebral perfusion.
Right femoral arterial and venous cannulation was established, followed by placement of a 12-French cannula in the right common carotid artery using the Seldinger technique. Cerebral perfusion was maintained at approximately 1 L/min before, during, and after systemic cardiopulmonary bypass, permitting controlled cerebral perfusion while systemic circulation was interrupted during the hazardous portion of the procedure.
During sternal reentry, dense mediastinal adhesions were encountered. The innominate vein was adherent to the posterior surface of the sternum and was inadvertently injured during sternal division. The vein was mobilized and subsequently repaired with a pericardial patch rather than primary closure, avoiding excessive tension and the risk of venous stenosis.
The pseudoaneurysm was entered, and the thrombus was evacuated. The defect involving the ascending aortic graft was repaired using a thin, flexible Dacron patch secured with a mattress suture. The patch was subsequently reinforced circumferentially with 4-0 polypropylene sutures. The heart remained beating throughout the operation.
Following completion of the repair, systemic perfusion was restored and the patient was separated from cardiopulmonary bypass. The total cerebral perfusion and bypass time was 52 minutes, systemic clamp time was approximately 23 minutes, and systemic circulation was interrupted for approximately 30 minutes. The entire operation lasted approximately two hours. The patient was discharged approximately four to five days later and was reported to have recovered without significant complication.
The principal educational point is the use of continuous antegrade cerebral perfusion during hazardous redo sternotomy for a pseudoaneurysm or contained rupture located immediately beneath the sternum. The approach is presented as an alternative to profound hypothermia and circulatory arrest, with the potential to shorten operative duration while maintaining cerebral perfusion during systemic circulatory interruption.
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3 Comments
Did you cool the body at all ? Or just shut the pump off warm with antrgrade cerebral perfusion
We did not cool body. As long as the brain is well perfused, the body can withstand 30 minutes of arrest without difficulty. The key is the brain. Look for the videos in the atlas about cerebral perfusion and thanks for your question. V Gaudiani
Hi. So there was no x clamp as I understand? it was all beating heart? No plegia. So how long would you tolerate lower body circ arrest ? I presume during the lower body circ arrest heart would be beating at 37C? Would you x clamp the heart if it fibrillated? how would you vent it?
2nd, I am confused by “air getting into aorta on reentry ” do you mean when pt is cooled to 18 under circ arrest? bcz air should not enter the aorta if not under circ arrest as it is high pressure circulation.
Many Thx for your insightful educational videos, ideas and very positive input.