Christian A. P. Schmidt, MD, PhD, Markus J. Wilhelm, MD, Dieter O

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Presentation transcript:

Veno-venous perfusion to cool and rewarm in thoracic and thoracoabdominal aortic aneurysm repair Christian A.P. Schmidt, MD, PhD, Markus J. Wilhelm, MD, Dieter O. Mayer, MD, Zoran Rancic, MD, PhD, Annette Bangemann, MD, Christian Felix, MD, Frank J. Veith, MD, Mario L. Lachat, MD Journal of Vascular Surgery Volume 58, Issue 1, Pages 33-41 (July 2013) DOI: 10.1016/j.jvs.2013.01.030 Copyright © 2013 Society for Vascular Surgery Terms and Conditions

Fig 1 Conventional veno-arterial femoral cooling as cooling and rewarming method for open surgery in thoracoabdominal aortic aneurysms (TAAAs). A limited retrograde flow in the atherosclerotic descending aorta in case of normal cardiac output is shown. Journal of Vascular Surgery 2013 58, 33-41DOI: (10.1016/j.jvs.2013.01.030) Copyright © 2013 Society for Vascular Surgery Terms and Conditions

Fig 2 In case of reduced cardiac output because of surgical manipulation or systemic hypotension, increased retrograde flow might lead to dislodging of unstable plaque material that causes cerebral embolization. Journal of Vascular Surgery 2013 58, 33-41DOI: (10.1016/j.jvs.2013.01.030) Copyright © 2013 Society for Vascular Surgery Terms and Conditions

Fig 3 Veno-venous cooling and rewarming of patients was achieved by percutaneous insertion of a 28 F Fem-Flex II cannula into the left common femoral vein (draining cannula positioned in the infrarenal inferior vena cava) following systemic low-dose heparinization (bolus of 100 IU/kg body weight). An 18 F Fem-Flex II perfusion cannula was placed into the right common femoral vein and positioned in the superior vena cava. Using a heparin coated tip-to-tip system (5000 IU heparin in cardiopulmonary bypass [CPB] priming solution) perfusion was initiated prior to thoracotomy or thoracoabdominal incision and patients were cooled. Journal of Vascular Surgery 2013 58, 33-41DOI: (10.1016/j.jvs.2013.01.030) Copyright © 2013 Society for Vascular Surgery Terms and Conditions

Fig 4 After proximal aortic cross-clamping for thoraco-abdominal aortic aneurysm repair (TEVAR), veno-venous perfusion was switched to veno-arterial perfusion through common iliac arteries combined with selective renovisceral blood perfusion. Both venous cannulae served at this stage as draining cannulae. After completion of aortic repair, the arterial cannulae were removed, and patients were rewarmed by veno-venous perfusion. Journal of Vascular Surgery 2013 58, 33-41DOI: (10.1016/j.jvs.2013.01.030) Copyright © 2013 Society for Vascular Surgery Terms and Conditions

Fig 5 Veno-venous perfusion allowed effective cooling at 3.3°C/h using a flow of 2763 ± 780 mL/min (about 50% of cardiac output) and gradient adjustment with a minimum temperature of 30°C. Target temperature was defined as 32°C or less. Changes in temperature were significant from 10 min onwards compared to start of cooling (P = .001, as indicated by *). Journal of Vascular Surgery 2013 58, 33-41DOI: (10.1016/j.jvs.2013.01.030) Copyright © 2013 Society for Vascular Surgery Terms and Conditions

Fig 6 Hemodynamics cooling. Veno-venous cooling did not influence hemodynamic and pulmonary stability as shown by heart rate (HR), mean arterial pressure (MAP), oxygen saturation (SaO2), and central venous pressure (CVP). During surgical dissection of the proximal descending aorta and single lung ventilation, additional oxygenation was achieved via the perfusing cannula (extracorporeal membrane oxygenation). Journal of Vascular Surgery 2013 58, 33-41DOI: (10.1016/j.jvs.2013.01.030) Copyright © 2013 Society for Vascular Surgery Terms and Conditions

Fig 7 Rewarming of patients was equally effective (3.9°C/h) using veno-venous perfusion at a flow of 2962 ± 870 mL/min and gradient adjusted rewarming with a maximum blood temperature of 38°C. Target temperature was defined as 36°C and above. Changes in temperature were significant from 20 minutes onward compared with start of rewarming (P = .03, as indicated by asterisks [*]). Journal of Vascular Surgery 2013 58, 33-41DOI: (10.1016/j.jvs.2013.01.030) Copyright © 2013 Society for Vascular Surgery Terms and Conditions

Fig 8 Hemodynamics rewarming. Veno-venous rewarming had no negative influence on hemodynamic and pulmonary stability as shown by heart rate (HR), mean arterial pressure (MAP), oxygen saturation (SaO2), and central venous pressure (CVP). HR increased significantly by 34.3% upon rewarming from 30.5°C to 36.3°C, but stayed within physiological limits (P = .01 from 40 minutes onward compared with start of rewarming, as indicated by asterisks [*]). Journal of Vascular Surgery 2013 58, 33-41DOI: (10.1016/j.jvs.2013.01.030) Copyright © 2013 Society for Vascular Surgery Terms and Conditions