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Whole body perfusion utilizing two cannulas for the upper and lower body halves enables continuous oxygen supply to the brain, kidneys, and intestinal organs while avoiding cooling to a low core temperature during aortic arch reconstruction in neonates with hypoplastic left heart syndrome, hypoplastic or interrupted aortic arch, and related malformations. 
 
This video presents the technique of arterial cannulation for whole body perfusion aimed at facilitating aortic arch reconstruction in neonates. The goal of this cannulation technique is to ensure whole body perfusion during congenital heart surgery, particularly when reconstructing the aortic arch, for example during the Norwood procedure. Utilizing a prosthesis instead of direct cannulation of the brachiocephalic artery facilitates unobstructed blood flow to the right carotid and subclavian arteries. Another advantage of using a prosthesis is the ability to rapidly connect ECMO to the prosthesis if weaning from cardiopulmonary bypass is not possible. 
 
After a standardized sternotomy, the thymus was partially excised to ensure carefree access to the brachiocephalic artery. The innominate vein was circumferentially dissected. Careful circumferential dissection of the brachiocephalic artery up to its bifurcation is important for thorough mobilization. During this process, caution must be taken to protect the right recurrent laryngeal nerve, which is best accomplished by staying directly on the artery’s adventitia. 
 
Before the operation started, an arterial pressure measurement line was placed in the right radial artery by the anesthetist, allowing for continuous monitoring of blood pressure downstream of the cannulation site during the clamping of the aortic arch and snaring of the head vessels toward the arch. Since the anastomosis of a PTFE prosthesis to the brachiocephalic artery requires clamping of the artery, a U-shaped 6-0 monofilament nonabsorbable suture was placed to prepare for the insertion of a pressure measurement line into the ascending aorta. This setup allows for continuous invasive arterial monitoring during creation of the anastomosis between the brachiocephalic artery and the PTFE prosthesis. 
 
The venous cannulation site was prepared using a 5-0 monofilament nonabsorbable purse-string suture around the right atrial appendage. 
 
The right subclavian artery was looped, and a marking suture was placed at the inferior border of the artery, close to its origin. The brachiocephalic artery was clamped with a Satinsky clamp while rotating the artery slightly upward with the forceps so that the caudal edge of the artery was facing toward the surgeon. A 3.5 mm PTFE prosthesis was tapered so that, after the anastomosis, it pointed toward the right pulmonary artery, similar to a mBTT-shunt. An incision was made along the rim of the artery created by the clamp extending it to approximately 5 mm in length and aiming at the previously placed marking suture. 
 
For the anastomosis of the brachiocephalic artery with the PTFE prosthesis, a 7-0 monofilament nonabsorbable continuous suture with a small needle was utilized. This smaller needle helps with hemostasis of the prosthesis. The suture was initiated at the proximal incision corner and on the inside of the vessel, with a covered clamp placed on this side of the thread after the first stitch. The second stitch was placed with the free end of the thread at the inside of the prosthesis’ shorter tapered corner. 

The anastomosis was then continued with the same thread in a forehand manner, first placing distant stitches for the first two or three stitches before lowering the prosthesis down to the vessel and pulling the distal end of the prosthesis beneath the innominate vein. To keep the thin vessel wall intact, grasping with forceps should be limited to the vessel’s adventitia. After passing the distal corner of the incision in the brachiocephalic artery, the covered clamp was switched to the opposite side of the thread, and the top side of the anastomosis was finished with the forehand technique running toward the surgeon. 

After the removal of the Satinsky clamp, the prosthesis was deaired by flushing it with blood before being immediately clamped again. An 8 French cannula was then inserted and secured with a multifilament nonabsorbable thread. The inside tube of the cannula was subsequently removed, and a clamp was placed at the end of the arterial cannula. The cannula was connected with one of the arterial tubes of the heart lung machine, ensuring that no air bubbles got trapped inside the tubes. The second arterial connection was used to facilitate whole body perfusion. The right atrial appendage was incised while making sure that the scalpel was angulated correctly to avoid cutting through the opposing side of the appendage. A 16 French cannula was inserted and pulled back as far as possible to ensure good drainage of the right atrium. The cannula was then snared and secured with a multifilament nonabsorbable thread and cardiopulmonary bypass was initiated. 
 
To directly cannulate the descending aorta, the assisting surgeons needed to move the diaphragm caudally using a spatula while simultaneously carefully luxating the heart with the sucker. The ECG was monitored to recognize any signs of coronary ischemia. The left pleural space was opened, and the pulmonary ligament was divided using cauterization to treat lymphatic tissue leading to the descending aorta. The descending aorta was then circumferentially dissected and looped, taking care not to damage the thoracic duct. A diamond-shaped purse string was placed using a 5-0 monofilament nonabsorbable suture. 
 
An incision was made, and the second arterial cannula was placed into the descending aorta and pulled back as far as possible to prevent blood flow obstruction by the aorta’s vessel wall. The cannula was then snared and secured with a multifilament nonabsorbable thread. The inner tube was removed, and the first cannula was clamped. Retrograde flushing of the cannula was then conducted by slightly opening the proximal clamp, allowing for connection to the heart lung machine via a Y-shaped connector without having to stop cardiopulmonary bypass. It is important to use the same size arterial cannulas so that blood flow is regulated by the blood vessels' resistance rather than by size of the cannula. During aortic arch reconstruction, the three head vessels were snared and the descending aorta was clamped far below the arterial duct. Reduction of flow during aortic cross-clamping was not necessary using this perfusion technique. 

References

1. Kreuzer M, Sames-Dolzer E, Schausberger L et al. Double-arterial cannulation: a strategy for whole body perfusion during aortic arch reconstruction. Interact Cardiovasc Thorac Surg. 2018 Nov 1;27(5):742-748. doi: 10.1093/icvts/ivy147. PMID: 29722889.

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