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Re-do Surgery for Type A Aortic Dissection: Aortic Rupture During Sternotomy

Monday, August 10, 2015

This video demonstrates the author’s technique for re-operation on type A aortic dissection. The patient developed aortic dissection while weight-lift training in December 2013. A CT scan revealed a large intimal tear at the aortic arch. The patient’s ascending aorta was replaced with a Dacron graft. The follow-up studies showed an enlarging dissecting aneurysm. The author operated on the patient in July 2014. To prevent blood loss and brain ischemia caused by aortic rupture during sternotomy, the patient was put on pump through the femoral artery, bilateral carotid arteries, and femoral vein. During the sternotomy, the Dacron graft was cut. The systemic perfusion was stopped, and the brain was protected by carotid perfusion. The total aortic arch was replaced with a vascular ring connector, and a fresh elephant trunk was inserted with a guide-wire pulling technique. Blood loss was 550 ml. The heart ischemic time was 143 minutes and pump time was 196 minutes.

Comments

WRONG SAW: Respectfully, the video shows using an inappropriate saw for re-do sternotomies. There are re-do oscillating saws that should be used instead. Best Regards
I certainly agree. An oscillating saw is an absolute necessity; failing which, the obvious catastrophic event unfolded. It is always prudent to note that adequate cardiac decompression may not occur even with peripheral bypass techniques. I may append a case of re-do sternotomy for graft failure when the sternotomy saw completely transected the adherent right ventricle with disastrous consequences.
I completely agree, oscillating saw is a must. This is a tough redo and on the CT scan scan it is clear that the ascending graft is stuck to the posterior sternum, necessitating (in my opinion) right axillary artery dissection and at least a femoral venous wire prior to sternotomy. Although I do have to say that I have used this technique of pulling down the elephant trunk (Siena graft) from the femoral artery and I think this is useful.
SAFETY ALERT: It appears that the ctsnet has again, on this occasion, proven important for patient safety and quality improvement, having offered an opportunity for transcontinental expert discussion and hopefully change of surgical practice. It seems, from the three comments so far, that we have reached an impromptu ad hoc consensus: a piece of equipment shown in this video (saw) is dangerous for this type of procedure ( sternal re-entry) and a serious peri-operative complication ( conduit trauma and haemorrhage) could have been avoided should the correct alternative ( oscillating saw) was used instead. I am delighted that the cannulation strategy has probably prevented exsanguination and mors in tabula. I would like therefore to give credit to Dr. Jeng Wei and his team for planning and executing pre-emptive multiple peripheral arterial cannulation. However, I feel it is important to have Dr. Wei's agreement in this forum that his preference card for re-dos in his unit in Taiwan should hitherto substitute the standard with the oscillating saw. Kindest Regards
If redo aortic surgery is not complicated. The surgeons should be congratulated for their surgical skills. Was the patient cooled down before skin incision? As already commented with this saw the operation is doomed to fail. Second, in dissected aorta, the guide wire can end frequently in the false lumen leading to mal perfusion. If the planned surgery include positioning of guide wires, it will be safer to place them preoperatively under fluoroscopy in the cathlab if hybrid OR is available
I have recently done a few of these. I agree with osc. saw. I start by placing a femoral wire with fluoro and IVUS. Over that i place a Coda balloon as an internal cross clamp. Then axillary artery/femoral vein bypass. If the ascending is entered on sterno, then blow up the balloon and charge in. And give hand held antegrade plegia.
I also agree with the above comments. I want to add that I was taught the tear must be removed with the first repair. An arch tear with only the ascending aorta replaced does not fix the dissection. The redo was predictable.
Thank you for your comments! I have been using oscillating saw for redo sternotomy for over 30 years. However, I found that in cases of severe adhesion, rupture of the aorta was still inevitable in many instances. My current practice is to put the patient on pump before sternotomy no matter what kind of saw is used. This video is not talking about the methods of redo sternotomy. My focus is how to protect the brain if there is massive bleeding caused by aortic rupture during sternotomy, and how to replace the aortic arch in a simple way.
Regarding guide wire, it almost always passes through the true lumen during circulatory arrest. My observation is that if there is no blood flow in the aorta, the true lumen will open and the false lumen will collapse. I had been using guide wire to insert elephant trunk in over 100 cases, and in only 2 cases the guide wire couldn't pass through the true lumen.
One method to deal with a graft adherent to the undersurface of the sternum is to open the lower third of the sternum, ideally with an oscillating saw, and then dissect the aorta and other tissue from the sternum under direct vision. Alternatively, the dissection may be done with VATS/thoracosopic techniques after opening the lower sternum.
The oscillating saw is not the answer - it is dangerous sprays blood and bone marrow everywhere and has little place if any in redo sternotomy. The best technique for redo sternotomy is to use hooks and met scissors starting at the bottom and under direct vision. Once the lower sternum is clear from the bottom of the RV an internal mammary retractor is used with a hook to elevate the lower sternum - the dissection is progressed upwards often underdirect vision using long curved scissors cutting with the tips hard up against the back of the sternum progressing all the way up until the tips of the scissors are felt on the finger tip hooked around the top of the sternum having cleared under the back of the manubrium with the finger. The standard sternal saw can then safely be used without risk on entering medistinal structures. Here the preop risk assessment showed the graft and aorta lying right behind the sternum - therefore patient should be cannulated ready for bypass- if on dissection with scissors it was found there was not a plane of dissection between graft and sternum (which is unusual) then patient would put on bypass and cooled before proceeding to partially open the sternum up to the fused area and then use local retraction with hooks for exposure to dissect free the graft from the back of the sternum.
OF SAWS AND REDOS Respectfully to our esteemed colleague Dr. Gardner, the oscillating saw has being used in the vast majority of redo sternotomies worldwide and a number of first sternotomies. I personally find it SAFER under any circumstances, and prefer it in all cases as I have been taught and for simplifying the preference cards. Universal precautions (eye protection) should be universally applied. A suction is useful for the debris. The safety of the redo saw is easily demonstrated by testing it on soft tissue (I have seen colleagues testing it on their own finger!) I note that a hybrid of Dr. Gardner's elaborate (and in my opinion daring) technique WITH a 'redo' saw has been published in the beginning of the century as http://www.ncbi.nlm.nih.gov/pubmed/12058458 It would be useful to see what the community thinks on the matter.
I have seen surgeons redo sternotomies with the saw, as shown in this video, quite safely, but after dissection of the inferior sternum and blunt dissection under it superiorly (a Chitwood clamp does this job quite nicely) . The dacron graft should have peeled off the underside of the sternum with this technique. It is my view that the oscillating saw is safer, however. What I have learnt is that careful pre operatively planning meant that the graft rupture was managable. The wire facilitated placement of the elephant trunk is inspired. The author should be congratulated for posting this instructive video. Many thanks for this.
I really dont know what saw Dr. Wei used in his procedure as youtube is not allowed in my country and CTSNet would show the video in any other format. i request the CTSNet again to change the format so that people like us are not deprived of such valuable practical advises and news.
The saw I used to open the sternum is the conventional sternal saw. The reasons for me not to use oscillating saw in this case are: (1) The graft was tightly adhered to the sternum by CT scan and I predicted that even oscillating saw could cut the graft, and (2) We needed to open the whole sternum as soon as possible if we cut the graft, which couldn't be done by oscillating saw. As I mentioned previously, I had been using oscillating saw and sternal knife for re-do patients for more than 30 years. The procedure was stressful and I still had several cases of fetal hemorrhage, especially in aortic dissection. I myself will close the pericardium during the first operation, either with the patient's own pericardium or bovine pericardium, but many others leave the pericardium open so that the patient is vulnerable to bleeding during re-operation. In the recent years, I had never had a case of mortality if we put the patient on pump before re-sternotomy in all kinds of cardiac sugery, no matter what kind of saw was used.

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