Modified Cabrol Shunt After Complex Aortic Surgery Tomas A. Salerno, MD, Enisa M. F. Carvalho, BS, Anthony L. Panos, MD, and Marco Ricci, MD Division of Cardiothoracic Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida Uncontrollable hemorrhage during complex aortic sur- gery was controlled by a new modification of the Cabrol shunt, which is reported here. (Ann Thorac Surg 2008;86:669 –70) © 2008 by The Society of Thoracic Surgeons B leeding after complex aortic reconstructive proce- dures may be impossible to control in certain situ- ations [1]. Perigraft-to-right atrial connection for hemor- rhage control during aortic surgery was first described by Cabrol and colleagues [1] in 1978. Since then, modifica- tions of this technique have been reported by Hoover and colleagues [2] in 1987, and by our group in 1989 [3]. Here we report another modification of the Cabrol shunt. Technique Catastrophic hemorrhage was encountered during aortic surgery in a 69-year-old woman undergoing redo aortic valve replacement, requiring replacement of the ascend- ing aorta with a Hemashield graft (Boston Scientific Corp, Natick, MA). The operation was lengthy; because of friability of tissues, Teflon strips were used to reinforce both the proximal and distal aortic sutures lines using 4-0 polypropylene sutures. Bioglue (CryoLife Inc, Kennesaw, GA) was applied to secure hemostasis upon completion of the anastomoses. Due to long cardiopulmonary bypass time, hypothermia, and circulatory arrest, significant co- agulopathy developed after administration of protamine and blood products. On-going bleeding from many op- erative sites occurred, including bleeding from the aortic suture lines and surrounding tissues. Bleeding continued despite usage of conventional maneuvers, including ap- plication of sutures, topical hemostatic agents, and re- combinant factor VII. As a result, a bovine pericardial patch, measuring approximately 10  8 cm was appro- priately tailored to isolate the area of bleeding from the reconstructed ascending aorta as shown in Figure 1. Suturing the patch proceeded from the superior vena cava laterally on the patient’s right side along the right atrium inferiorly, and the border of the heart and pulmo- nary artery on the patient’s left side. Due to technical difficulties in dissecting a rather thin and frail right atrium, it was decided to connect the cavity covered by the bovine pericardial patch to the innominate vein using a number 6-mm Hemashield graft (Boston Scientific Corp). The anastomosis between the graft and the in- nominate vein was constructed using 6-0 polypropylene sutures. Bleeding was controlled, as blood from the aortic Accepted for publication Feb 29, 2008. Address correspondence to Dr Salerno, Jackson Memorial Hospital, University of Miami Miller School of Medicine, 1611 NW 12th St, Miami, FL 33136; e-mail: tsalerno@miami.edu. Fig 1. Illustration showing the patch of bovine pericardium sutured to the peri-aortic tissues. The patch is sutured to the superior vena cava on the patient’s right side, the right atrium and border of the heart (caudal aspect), the main pulmonary artery on the patient’s left side, and the distal ascending aorta and proximal aortic arch (cephalad). A 6-mm Hemashield graft (Boston Scientific Corp, Natick, MA) is then used to redirect blood leaking from the aortic repair site, collecting under the patch, to the innominate vein (ie, autotransfusion). © 2008 by The Society of Thoracic Surgeons 0003-4975/08/$34.00 Published by Elsevier Inc doi:10.1016/j.athoracsur.2008.02.096 FEATURE ARTICLES