Life-saving Cannulation Strategies in High-risk Resternotomy for Pediatric Patients: A Single-center Experience

Öz

Aim: Despite advances in surgical experience and imaging techniques, resternotomy (RS) in pediatrics remains a high-risk procedure due to its potential for heart and major vessel injuries. This study aims to retrospectively evaluate RS cases in our clinic, focusing on high-risk patients and examining the effectiveness of various cannulation techniques. Methods: This retrospective study,included pediatric patients under 18 years of age who underwent RS between August 2019 and December 2023. Exclusion criteria included intervals of less than 30 days between consecutive RS procedures. Patient demographics, diagnoses, and RS-related outcomes were extracted from medical records. High-risk factors for major cardiac and vascular injury during RS were identified, and patients were categorized accordingly. Major injuries and outcomes of the various cannulation techniques were analyzed. Results:Out of 1,718 sternotomies, 157 (9.1%) were RS procedures, with 33 patients (21%) classified as high-risk. Major cardiac and vascular injuries occurred in 7 patients (4.5%), and RS-related mortality was recorded in 2 cases (1.2%). For high-risk patients, the femoral artery and vein were commonly prepared for emergent or elective cannulation, with alternative strategies employed when femoral vessels were unsuitable for cannulation. Three patients undergoing carotid artery cannulation showed no signs of neurological complications, supporting its viability as an alternative strategy in pediatric high-risk RS. Conclusion: Resternotomy remains a challenging procedure with substantial risk for major bleeding, especially in high-risk cases. For complex cases, preparation for alternative cannulation methods remains crucial to manage unexpected complications effectively.

Anahtar Kelimeler

• Pediatrics
• resternotomy
• cannulation

Kaynakça

1. 1.Jacobs JP, Mavroudis C, Quintessenza JA et al:Reoperations for pediatric and congenital heartdisease: an analysis of the Society of ThoracicSurgeons (STS) congenital heart surgery database.SeminThoracCardiovascSurgPediatr CardSurgAnnu. 2014: 2-8.
2. 2.Backer CL, Mavroudis C. Pediatric cardiac surgery, 5th edn. West Sussex: Wiley-Blackwell, 2023: 143-59.
3. 3.Yuan S-M, Jing H. Palliative procedures forcongenital heart defects. Archives of cardiovasculardiseases. 2009; 102: 549-57.
4. 4.Kirshbom PM, Myung RJ, Simsic JM, et al. Onethousand repeat sternotomies for congenital cardiac surgery: risk factors for reentry injury. Ann ThoracSurg. 2009; 88: 158-61.
5. 5.Morales DL, Zafar F, Arrington KA, et al. Repeatsternotomy in congenital heart surgery: no longer arisk factor. Ann Thorac Surg. 2008; 86: 897-902
6. 6.Holst KA, Dearani JA, Burkhart HM, et al. Riskfactors and early outcomes of multiple reoperationsin adults with congenital heart disease. Ann ThoracSurg. 2011; 92: 122-8
7. 7.Dearani JA, Connolly HM, Martinez R, Fontanet H,Webb GD. Caring for adults with congenital cardiacdisease: successes and challenges for 2007 andbeyond. Cardiol Young. 2007; 17: 87-96.
8. 8.Elahi MM, Kirke R, Lee D, Dhannapuneni RR,Hickey MS. The complications of repeat mediansternotomy in paediatrics: six-months follow-up of consecutive cases. Interact CardiovascThorac Surg. 2005; 4: 356-9.

9. 9.Said SM, Dearani JA. Strategies for high-riskreoperations in congenital heart disease. In:SeminThoracCardiovascSurgPediatr Card SurgAnnul: 2014:9-21.
10. 10.Russell JL, LeBlanc JG, Sett SS, Potts JE. Risks ofrepeat sternotomy in pediatric cardiac operations.Ann Thorac Surg. 1998; 66: 1575-8.
11. 11.Zens T, Ochoa B, Eldredge RS, Molitor M.Pediatric venoarterial and venovenousECMO.SeminPediatrSurg: 2023: 151327.
12. 12.Mavroudis CD, Smood B, Grasty MA, Fuller S,Desai ND. A Technique for Safe Redo Sternotomy inPatients with Aortic Proximity to the Sternum.World J PediatrCongenit Heart Surg. 2022; 13: 89-91.
13. 13.Sfyridis PG, Mylonas KS, Kalangos A. AbdominalVessel Cannulation Before Resternotomy inComplex Congenital Heart Surgery. Ann ThoracSurg. 2020; 109: 219-21.
14. 14.Kogon B, Voss J, Villari C, et al. Utility ofintravenous catheters for femoral arterialcannulation in infants having complicated sternalre-entry. J ThoracCardiovasc Surg. 2007; 134: 746-9.
15. 15.Brancaccio G, Perri G, Della Porta M, et al. Use ofcarotid artery cannulation during redo sternotomyin congenital cardiac surgery: a single-centreexperience. Interact CardiovascThorac Surg. 2021;33: 119-23.
16. 16.Pahwa S, Stephens EH, Dearani JA. High-RiskReoperative Sternotomy-How We Do It, How WeTeach It. World J PediatrCongenit Heart Surg. 2020;11: 459-65.
17. 17.Temur B, Davutoglu A, Dogruoz A, et al. Utility ofCervical Cannulation During Difficult Resternotomyin Congenital Heart Surgery. World JPediatrCongenit Heart Surg. 2020; 11: 65-70.
18. 18.Reyes K, Schnabel L, Cooke S, Bleiweis M. Safesternal reentry in all age groups with theRultractResternotomy Retractor. J Card Surg. 2017;32: 639-41.
19. 19.Pace Napoleone C, Valori A, Crupi G, et al. Anobservational study of CoSeal for the prevention ofadhesions in pediatric cardiac surgery. InteractCardiovascThorac Surg. 2009; 9: 978-82.
20. 20.Tatewaki H, Sakamoto I, Ushijima T, Shiose A.Pulmonary Valve Replacement via LeftThoracotomy as an Alternative to Resternotomy.Ann Thorac Surg.2020; 110: e537-e9.