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Modified Cabrol-Shunt after Complicated Coronary and Aortic Surgery on Extracorporeal Membrane Oxygenator
Christoph Krapf, Severin Semsroth, Birgit Mair, Benedikt Treml, Michael Grimm, Ludwig Müller, Nikolaos Bonaros.
Medical University of Innsbruck, Innsbruck, Austria.

OBJECTIVE: A 74 years old male patient with a three vessels coronary artery disease underwent emergency coronary bypass operation. The preoperative patient’s therapy included ASA, Ticagrelor and Fondaparinux. Due to an intraoperative dissection of the ascending aorta an ascending aortic replacement with hemiarch was performed in deep hypothermic circulatory arrest and antegrade cerebral perfusion. Due to embolism-associated ischemia signs two additional grafts were performed but the patient could not be weaned from cardiopulmonary bypass. A veno-arterial extracorporeal membrane oxygenator (ECMO) was centrally installed through the femoral vein and the side-arm of the aortic prosthesis. The bleeding situation was devastating due to extensive coagulopathy and absent platelet function. Despite ECMO therapy the decision to perform a Cabrol-shunt was made.
METHODS: A bovine pericardial patch was attached on pulmonary artery, right ventricle, right atrial appendage, superior caval vein, innominate vein back to the pulmonary artery. Venous bypass grafts were placed in the edge between pulmonary artery and right ventricle and between right atrial appendage and superior caval vein. As the tip of vein cannula of the ECMO was placed in the right atrium to allow adequate drainage, the connection of the shunt to the right atrial appendage could result in air or thrombus embolism. To avoid this complication, a 6 mm Dacron-shunt was interposed between the pericardial patch and the innominate vein. The prostheses for the arterial ECMO-line was placed through the patch and sealed with surrounding suture.
RESULTS: After releasing the shunt we were able to control the bleeding situation. No ECMO complications occurred. Location of the bypass grafts allowed good flow. The transfer to the intensive care unit was possible within one hour. Fatefully the patient died two days later because of massive cerebral ischemia, probably associated with of intraoperative plaque embolization.
CONCLUSIONS: Using the innominate vein as a connection site of the modified Cabrol-shunt it is possible to control hemorrhage in a fatal bleeding situation in a patient under ECMO-therapy.


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