AORTIC ARCH THROMBOEMBOLECTOMY FOR THROMBUS IN TRANSIT: UTILITY OF BOTH ANTEGRADE AND RETROGRADE CEREBRAL PERFUSION WITH MODERATE HYPOTHERMIC CIRCULATORY ARREST
Vicente Valero, MD, Christian V. Ghincea, MD, Thomas Brett Reece, MD, Muhammad Aftab, MD.
Division of Cardiothoracic Surgery, University of Colorado School of Medicine, Denver, CO, USA.
BACKGROUND: Proximal aortic thrombus can lead to devastating embolic events. Careful cannulation and neuroprotective strategies are required for successfully thromboembolectomy. A 35-year-old gentleman with Factor-V Leiden mutation, multiple venous thromboembolisms, presented with recurrent cerebrovascular accidents despite compliance to dabigatran and clopidogrel. He was noted to have a 10 cm mobile thrombus extending from the non-coronary sinus to the mid-arch and another thrombus in transit within the innominate artery (IA). METHODS: After median sternotomy, cardiopulmonary bypass (CPB) was established via right axillary arterial and dual stage right atrial cannulation . Superior vena cava was cannulated for retrograde cerebral perfusion (RCP). Once cooled to 24°C, hypothermic circulatory arrest (HCA) was initiated. A longitudinal aortotomy was made. The thrombus, which was densely adhered to the non-coronary sinus and extended into the mid-arch across the ostia of the left common carotid artery, was carefully removed. RCP was then administered to flush out the 1.5 cm thrombus in the ostia of the IA and any embolic debris, followed by antegrade cerebral perfusion (ACP) via the axillary graft. Systemic circulation was re-established and aortotomy was closed. The patient weaned from CPB and extubated uneventfully. RESULTS: Postoperatively the patient had no neurologic deficits or evidence of end-organ malperfusion. He was bridged to warfarin, started on dual anti-platelet therapy, and discharged home in good condition. CONCLUSIONS: Right axillary cannulation and moderate HCA using RCP and ACP is a safe method for performing complex aortic arch thromboembolectomy in patients with extensive clot burden extending into arch and branch vessels.
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