Table 1.

Step-by-step construction of the Cabrol fistula

Step	Description
Pre-Cabrol	The aortic root, ascending, or arch procedure has been completed; protamine and coagulation factors have been given; and bleeding continues despite all conventional measures.
Pre-Cabrol	Often we wrap the distal anastomosis with a small-caliber graft to seal any bleeding from that area. (This wrap then provides secure “tissue” at the upper margin of a subsequent Cabrol fistula.)
Cabrol	A pericardial patch is sewn to cover the entire site of the aortic replacement. We use running 4-0 PROLENE. •This proceeds clockwise, from the left upper corner (patient’s left) of the surgical zone, down the right side, using connective tissue around the medial border of the PA. Note that there is usually a good edge of relatively strong tissue here, where the PA previously abutted the periaortic tissues. •The suture line continues horizontally toward the patient’s right, using the fibro-fatty tissue at or above the RV. •The suturing continues cephalad now, using any connective tissues found along the right atrium. This is the hardest site for finding good tissue. One can use the stump of the RA cannulation site as good tissue in this zone. Fortunately, the distance to be spanned here, on the patient’s right side of the Cabrol patch, is usually short—between the top of the RV and the pericardial reflection of the SVC. As one heads cephalad, the pericardial reflection along the SVC provides good tissue. •Finally, the upper horizontal portion of the anastomosis needs to be completed. One usually finds some suitable fibrofatty tissue underneath the innominate vein that serves well for suturing. This completes the quasi-rectangular patch over the surgical zone. We often put some BioGlue around the edge of the patch, which will harden and seal while the patch is unpressurized.
Temp vent	To decompress the patch at this point, before construction of the shunt, we make a tiny incision in the periphery of the patch and place a small vent catheter under the patch, which we then attach to strong suction from the cell saver. This pulls the patch into tight approximation to the tissues, like a “shrink wrap,” while simultaneously collecting the shed blood for retransfusion.
Shunt prox anast	We now construct the proximal anastomosis of the graft that will carry the blood to the RA. See text for details of conduit choices. We prefer a valved-conduit of some type, for unidirectional flow. We use 4-0 PROLENE.
Shunt distal anast	We now perform the distal anastomosis of the graft, to either the innominate vein (preferred) or the RA proper. (4-0 PROLENE). Note: The innominate vein is preferred, as raising the head of the bed can minimize the back pressure in the vein as needed.
Open shunt	The shunt is now opened and allowed to channel blood from the bleeding site under the patch back into the venous circulation.
Bleed conrol	Near-immediate control of hemorrhage is usually achieved.
Close Chest	We close the chest, in standard fashion.

(1) In some cases, the shrink wrap during construction of the Cabrol fistula leads to cessation of bleeding on its own, and there is no need at that point to complete the shunt. In such a case, we leave the large patch in place over the previous bleeding zone. (2) The Cabrol fistula is more easily accomplished effectively in reoperative cases, as the scarred tissues provide better substrate for suturing and there are intrinsically fewer degrees of freedom for shed blood to disperse. (3) We do not routinely re-explore patients the day after operation to decompress clot. We do so only if there is a pressure effect (rarely). PA, Pulmonary artery; RV, right ventricle; SVC, superior vena cava; RA, right atrium.