title: Selective aortic arch perfusion enables to avoid deep hypothermic circulatory arrest for extirpation of renal cell carcinoma with tumour thrombus extension into the right atrium.
abstract: OBJECTIVE
  Renal cell carcinoma with a tumour thrombus extending into the right heart chambers necessitates extensive combined urological and cardiac surgery. Maximum safety and exactness in extirpation of the caval and intracardiac thrombus is achieved under deep hypothermic circulatory arrest, at a price of its non-physiological burden and time constraints. We propose a simple surgical manoeuvre enabling selective arch perfusion allowing for a milder hypothermia and liberal interval of circulatory arrest.
  
  
  METHODS
  On a routine cardiopulmonary bypass via median sternotomy, the dissection is extended along the aortic arch to identify the origins of the supra-aortic vessels. After standard aortic cross-clamping and cardioplegic cardiac arrest at moderate hypothermia, a second cross-clamp is applied at the aortic arch beyond the left carotid artery. A selective closed aortic arch perfusion is started while the extirpation of the tumour thrombus from the right atriotomy and abdominal cavotomy is being performed under conditions of circulatory arrest.
  
  
  RESULTS
  Using selective aortic arch perfusion, successful and uncomplicated extirpation of voluminous caval and intracardiac tumour thrombi was accomplished in 3 presented patients. Unexpectedly difficult thrombus adhering to hepatic veins in 1 patient required 42 min of circulatory arrest. Postoperative courses were uneventful in all 3 patients.
  
  
  CONCLUSIONS
  Second aortic cross-clamp to start selective closed aortic arch perfusion provides excellent surgical control of the operative field over a liberal time interval during circulatory arrest under milder hypothermia.
authors.affiliation: Department of Cardiac Surgery, Charles University in Prague, Faculty of Medicine and Faculty Hospital Hradec Kralove, Hradec Kralove, Czech Republic.
authors.forename: Pavel
authors.initials: P
authors.lastname: Zacek
authors.forename: Jan
authors.initials: J
authors.lastname: Dominik
authors.forename: Milos
authors.initials: M
authors.lastname: Brodak
authors.forename: Miroslav
authors.initials: M
authors.lastname: Louda
mesh_terms: D000368:Aged; D001013:Aorta, Thoracic / Q000503:physiopathology / Q000601:surgery*; D002292:Carcinoma, Renal Cell / Q000473:pathology / Q000601:surgery*; D006348:Cardiac Surgical Procedures / Q000009:adverse effects; D050792:Circulatory Arrest, Deep Hypothermia Induced / Q000009:adverse effects; D005260:Female; D006325:Heart Atria / Q000473:pathology / Q000601:surgery*; D006801:Humans; D007680:Kidney Neoplasms / Q000473:pathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009361:Neoplasm Invasiveness; D009392:Nephrectomy / Q000009:adverse effects; D061646:Operative Time; D010477:Perfusion / Q000009:adverse effects / Q000379:methods*; D012039:Regional Blood Flow; D013997:Time Factors; D016896:Treatment Outcome
keywords: Cerebral perfusion; Circulatory arrest; Deep hypothermia; Intracardiac tumour thrombus; Renal cell carcinoma