2024-03-20 12 Presentation Crossover Surgical Video

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Dr David Lehanbauer from CCHMC demonstrating a surgical video. The procedure is “uncrossing procedure.” It involves mobilizing and re-anastomosing the aorta to relieve compression on the trachea and esophagus caused by a circumflex aorta.

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>> See how much wider now that the space for the esophagus and the trachea is now with that comerol is completely resected and the aberrance of clavian moved out of the way. It’s much larger than that entire ruler and there’s the finishing shot of the comerols which has been resected. So I think one of the take-home points is that vascular rings are much more complex than simply dividing the ring and if you have a patient that has that exact setup with the aberrance of clavian and comerols then there should be consideration amongst you and your team about potentially resecting that. Next case is a 15-month-old with a right dominant double arch that had prior repair. They divided the left arch and performed a posterior aorta pexy and he represents with symptomatic breathing. Anybody, any takers on what we’ve got here? So he’s got, you can see the significant tracheal compression. You can see an ascending aorta on the right and then a descending aorta on the left. So he has a circumflex aorta. Doing the bronchoscopy you can see the vascular compression. You can see some of the tracheomalacia. The Boston group back in 2020 published a very large series and they were strong advocates for doing an uncrossing procedure and a posterior tracheal pexy to help address the malaysia and to facilitate that you’ve also got to mobilize the esophagus to get it away from the spine so you can tack back down the posterior membrane. Here just this year in 2024 the Kentucky group published their series. The thing that I think is notable about this is that it’s the largest series to date. It’s over 20 years, two institutions and yet it only includes 11 patients. So I’m only, I’m very suspicious that there’s a lot of these patients with circumflex aorta walking around that people are just unaware that there’s a very viable and durable solution for these patients and you can see here in the results that almost all the patients or all the patients had resolution of symptoms just one of them required a reoperation. Over the course of that 20 year period there’s been a learning curve that’s been satisfied. We’ve transitioned away from hypothermic circulatory arrest, progressed to ACP to refuse the brain. The length of say is shorter and consistently short and the number of complications especially dreaded complication since we’re working on the arch on both sides bilateral recurrent nerve palsies has also been reduced. So to help people hopefully understand what a uncrossing procedure is I’ve got a quick video here demonstrating the technique and hopefully this will make sense. Alan O’Donnell who’s my physician assistant put this together and he’s technically very gifted with video. So here we are this is that patient we’re talking about with a circumflex aorta. So we are mobilizing the ascending aorta. We’re getting proximal control around that innominate. Here is that patient had prior surgery it had their vascular ring and left arch divided but still had their ligamentum intact probably due to scar tissue so we’re completely dividing that. Now we’re getting around the arch vessels that is the left carotid. We’re going to get around the left subclavian. We’re going to go further around the arch to gain control of the right carotid and the right subclavian. So this the circumflex aorta starts on the right side and curves posteriorly around and completely encircles the trachea and the esophagus. Now we’re working on the descending aorta to gain control. We’re using electrical carotid to take down the collaterals and mobilize enough room to gain vascular control. We’re cannulating for bypass putting a pipe in the aorta. We’re cannulating the right atrium and then we will initiate cardiopulmonary bypass. We’re putting an event into the left heart so that the heart doesn’t get distended. Completing the rest of our mobilization of the aorta. Now we have control of the descending aorta. We’re putting the heart to sleep. We’re cross clamping the ascending. We’re performing antigrade cerebral perfusion which is where we advance the perfusion the bypass machine into the right carotid so that the the right brain is perfused during this portion so we can open up and work on the aorta on the inside and still perfuse the brain which is different than deep hypothermic circulatory arrest where we didn’t perfuse the body during this portion of the procedure. We’re dividing the circumflex aorta and now we’re passing it behind and up around so that we can re-anastomose this aorta now that it’s fully mobilized. There is the descending aorta being sounded and to orient to the anatomy. There’s the descending aorta. There’s the left carotid and the ascending aorta and this is the portion where we’re going to uncross and re-anastomose our descending aorta to our ascending aorta. The critical thing that you guys can’t see here is that the the trachea and the esophagus that were encircled by this aorta are no longer present and now that we’ve brought the aorta anterior those things are no longer being compressed. Making our aortotomy into the ascending aorta and now we’ll perform our anastomosis. So my hope, like I said, you know at two of the busiest centers in the country in the United States there’s only a handful of patients so if you guys do encounter these patients with circumflex aorta hopefully you’ll be able to to know that this is a very good and durable therapeutic option for these patients to relieve their airway and esophageal symptoms. Re-perfusing the heart, removing the clamps off the head and neck vessels, now we’re perfusing the entire body. The end of the integrative cerebral perfusion. This is that portion of the circumflex aorta which we divided. Now we’re over sewing that since the aorta is no longer connected there and that stump is short so it should not press on the trachea or the esophagus. Decannulating, making the bleeding stop, the vein of the cardiac surgeon. That’s it. Thank you very much. [APPLAUSE] (audience applauding)