Antegrade cerebral perfusion by axillary artery and left carotid artery inflow at moderate hypothermia.

Cerebral protection during hypothermic circulatory arrest was obtained by combining right carotid perfusion through the axillary artery with selective perfusion of the left common carotid artery in ten patients. We believe that the proposed technique offers several advantages. (1) The axillary artery is generally free from atherosclerosis. (2) It eliminates the risk of retrograde embolization. (3) It provides antegrade perfusion of the true lumen in aortic dissection. (4) Antegrade cerebral perfusion is never interrupted. (5) Bihemispheric perfusion is assured. (6) The risk of air embolysm during carotid cannulation is reduced.     

Simultaneous selective cerebral perfusion and systemic circulatory arrest through the right axillary artery for aortic surgery

The duration of safe circulatory arrest for replacement of the ascending aorta for a type A dissection, without additional cerebral perfusion measures, is not clearly defined. If prolonged periods (> 60 minutes) are anticipated, retrograde cerebral perfusion or selective antegrade carotid perfusion may be required. The latter requires separate cannulas with subsequent snaring of the cerebral vessels, which may be time consuming and cumbersome. We propose an alternative method whereby the right axillary artery is cannulated for cardiopulmonary bypass and, when the desired hypothermic temperature is achieved, the flows are turned down to 500 mL/min. The origin of the innominate artery is then occluded establishing selective antegrade right carotid artery perfusion. The distal ascending or aortic arch anastomosis is then performed while the remainder of the body is under selective systemic circulatory arrest. The proximal aortic anastomosis is performed after the graft is clamped proximally and flows return to appropriate perfusion levels.     

单侧与双侧顺行性脑灌注的前瞻性随机对照研究

目的 比较全主动脉弓替换术中单侧顺行性脑灌注（ASCP）和双侧ASCP的脑保护效果。方法 16例全主动脉弓替换术病人随机分为单侧ASCP组和双侧ASCP组，每组各8例。两组均行术前、术后颅脑计算机体层摄影（CT）、术中均动态监测无名动脉及左颈总动脉压力，均行颈内静脉球血样血气分析。结果 两组各有1例出现短暂性神经功能异常。在ASCP期间单侧组无名动脉压高于左颈总动脉压（P〈0．01），而双侧组无名动脉压与左颈总动脉压相同。两组间各时间段颈静脉血氧分压、颈静脉血氧饱和度差异无统计学意义（P〉0．05）。结论 在基底动脉环完整，存在有效侧支循环条件下，单侧ASCP及双侧ASCP均能取得良好效果。单侧灌注操作较为简便，双侧灌注在ASCP期间两侧灌注压较为均衡，双侧灌注是否增加脑栓塞的危险尚需进一步研究。     

Direct cannulation of the common carotid artery during the ascending aortic or aortic arch replacement

Objective: To evaluate cerebral perfusion using direct cannulation into the common carotid artery. A new technique is needed to protect brain ischemic injury during ascending aortic or aortic arch replacement. Methods: This technique was evaluated for patients who would have difficulty maintaining adequate cerebral perfusion during surgery. The procedure was performed when patients had the following diagnoses: pseudoaneurysm formation in contact with the sternum with the risk of aneurysmal rupture (n=5), acute aortic dissection with compression of the true lumen of the innominate artery by the pseudolumen (n=3), or a large volume of thrombus in the lumen of the aneurysm with the risk of cerebral thromboembolism if standard extracorporeal circulation was used (n=2). The perfusion catheter was cannulated into one side of the common carotid artery (right side: n=6, left side: n=4) and mean perfusion flow rate was found to be 175 mL/min. The operative procedures consisted of ascending aortic and aortic arch replacement with coronary artery bypass grafting in six patients, ascending aortic replacement in 2 patients, and innominate artery reconstruction/innominate artery and right subclavian artery reconstruction in one patient. Results: No cerebral accidents or deaths occurred while patients were hospitalized. We have followed up patients for a mean of 2.1 years (maximum 3.6 years), with no complications noted from the surgical procedure. Conclusions: Direct cannulation of the common carotid artery is a simple, safe, and acceptable cerebral protection for patients undergoing aortic or aortic arch replacement procedures in the patients with these specific conditions.     

Aortic arch repair with right brachial artery perfusion

Background. To determine the effectiveness of unilateral selective cerebral perfusion for aortic arch repair and to discuss possible modifications to enhance technical simplicity.

Methods. In the period between January 1996 and April 2001, 104 patients underwent aortic arch repair with the use of right brachial artery low flow (8 to 10 mL/kg per minute) antegrade selective cerebral perfusion under moderate hypothermia (26°C). Mean patient age was 52 ± 12 years. Sixty-four patients presented with Stanford type A aortic dissection, including 12 with acute dissection; 38 patients had aneurysmal dilatation of the ascending aorta and aortic arch; and 2 patients had isolated arch aneurysm. Ascending and partial arch replacement was performed in 50 patients; ascending and total arch replacement in 33 patients; ascending and descending arch replacement in 19 patients; and isolated arch replacement in 2 patients.

Results. Mean antegrade cerebral perfusion time was 39 ± 22 minutes. One patient with acute proximal dissection died because of cerebral complications. One other patient developed right hemiparesis, which resolved during the second postoperative month without sequela. Other than these 2 cases (1.9%), no other neurologic event was observed.

Conclusions. The technique of low flow antegrade selective cerebral perfusion through the right brachial artery may be used for a vast majority of aortic aneurysms and dissections requiring arch repair. This technique does not necessitate deep hypothermia, requires shorter cardiopulmonary bypass and operation times, has the advantage of simplicity, provides optimal vascular repair without time restraints and, in terms of clinical results, is as safe as other techniques for cerebral protection.     

Aortic arch and proximal supraaortic arterial repair under continuous antegrade cerebral perfusion and moderate hypothermia.

PURPOSE: In this prospective study the clinical and neurological outcome of continuous antegrade cerebral perfusion (ACP) and moderate hypothermia was evaluated in patients undergoing ascending and aortic arch repair including reconstruction of the proximal supraaortic arteries. METHODS: In 50 consecutive patients (mean age 47 yr, range 22-70) aortic arch and supraaortic arterial repair was performed: ascending aorta and aortic arch (n=34) and aortic arch and Bentall procedure (n = 16). In 12 patients the distal anastomosis was performed using the elephant trunk technique. Test-clamping of the innominate artery for 3 min was performed under EEG-monitoring followed by the same procedure for the left carotid artery. Cardiopulmonary bypass was instituted and the innominate artery replaced by a polyester graft before antegrade perfusion was carried out through the graft. While cooling to 28-30 degrees C, the left carotid artery was similarly treated with subsequent antegrade cerebral perfusion. The distal anastomosis was made at or beyond the left subclavian artery under circulatory arrest. During rewarming the innominate and carotid polyester grafts as well as the subclavian artery were anastomosed to the main graft, while antegrade cerebral perfusion was continued. RESULTS: In 46 patients antegrade cerebral perfusion was achieved with a mean volume flow of 12 ml/kg/min and a mean arterial pressure of 54 mmHg. EEG-monitoring delineated stable and symmetrical recordings. In four patients antegrade flow (mean 15 ml/kg/min) and pressure (mean 65 mmHg) had to be increased to establish baseline EEG-recordings. The mean time of circulatory arrest was 18 min.The overall hospital mortality was 6%: two patients died from cerebral infarction and one patient suffered from a ruptured abdominal aortic aneurysm. Three patients (6%) developed a temporary neurological deficit which resolved spontaneously. Two patients (4%) developed renal failure requiring temporary hemodialysis. Pulmonary complications occurred in 12 patients (25%). CONCLUSION: Continuous antegrade cerebral perfusion via selective grafts to the innominate and carotid arteries offers adequate protection in patients undergoing replacement of the ascending aorta or aortic arch and great vessels. This technique allows radical repair and optimal vascular reconstruction without time restrains and avoids the necessity for profound hypothermia     

External carotid endarterectomy with internal carotid artery transposition flap angioplasty for symptomatic internal carotid artery occlusion

The external carotid artery is an important collateral pathway for cerebral perfusion when the internal carotid artery is occluded. After internal carotid artery occlusion, there is a definite risk of ipsilateral neurological events. The authors retrospectively examined their experience with endarterectomy of the external carotid artery for symptomatic internal carotid artery occlusion. Results based on the authors' experience and on historical data show external carotid endarterectomy to be a safe procedure. Obliteration of the cul-de-sac appears to be a very important factor in the prevention of reocclusion or recurrence of symptoms after external carotid endarterectomy. Use of the internal carotid artery stump for patching of the endarterectomized external carotid artery is both safe and effective in treating symptomatic internal carotid artery occlusion.     

The haemodynamic value of external carotid artery collateral blood supply in carotid artery disease

In the presence of severe obstruction of the internal carotid artery (ICA) blood supply to the ipsilateral hemisphere may be provided by collaterals. Whereas the circle of Willis in many cases makes a substantial contribution to cerebral perfusion, the value of collateral blood supply originating from the external carotid artery (ECA) is not clear. In thirty-five patients undergoing carotid endarterectomy (24 with proven external carotid artery collaterals) intra-arterial blood pressures were measured across the ICA stenosis, prior to endarterectomy. In order to evaluate the haemodynamic value of ECA collaterals, the distal ICA pressure was measured with and without the ECA clamped. In addition, volume blood flow in the common carotid artery was measured with and without the ECA clamped, before and after endarterectomy. No significant change in distal ICA pressure was observed when the ECA was clamped, whether or not external carotid artery collaterals had been demonstrated preoperatively. The greatest reduction in mean distal ICA pressure observed upon ECA clamping was 8 mmHg. However, this only occurred in three of 11 patients with a severe pressure reduction across the stenosis. ICA blood flow increased significantly following endarterectomy whereas ECA flow was reduced. This study indicates that ECA collaterals in most cases do not contribute substantially to cerebral perfusion. Endarterectomy of the ECA, in order to improve cerebral circulation, seems justified only in selected cases, where the distal ICA pressure has been shown to be severely reduced.     

Total arch replacement using a 4‐branched vascular graft without circulatory arrest

The technical essentials of the procedure include femoral artery cannulation, selective antegrade cerebral perfusion for brain protection, total arch replacement with a 4‐branched vascular graft, implantation of the special open stented graft into the descending aorta, moderate hypothermic balloon occluding descending aorta at 25℃. This technique allows arch reconstruction to be debranched first and upper part of the body is perfused via the 4‐branched vascular graft, ensuring antegrade true lumen cerebral perfusion rapidly secured, the descending aorta is arrested by balloon occluding and early rewarming and reperfusion after distal anastomosis to minimize organs ischemia.     

Extrathoracic cannulation of the left common carotid artery in thoracic aorta operations through a left thoracotomy: preliminary experience in 26 patients

BACKGROUND: In aortic operations performed through a left thoracotomy, which require total bypass and deep hypothermic circulatory arrest, femoral artery cannulation is commonly used for arterial perfusion. This route limits the time of safe circulatory arrest and is associated with the risks of retrograde embolization or, in the case of aortic dissection, malperfusion of the vital organs. To overcome these problems, we have used cannulation of the extrathoracic left common carotid artery to ensure a central a route of arterial perfusion in these operations. The preliminary results are presented. METHODS: Between December 1999 and April 2001, we used left common carotid artery cannulation in 26 operations on the thoracic aorta performed through a posterolateral thoracotomy with an open technique during deep hypothermic circulatory arrest. Institutional review board approval and informed consent were obtained. The indications included perforating atherosclerotic ulcer (n = 5), chronic aortic aneurysm (n = 9), acute type B aortic dissection (n = 3), and chronic dissection of the thoracic aorta (n = 9). Transcranial Doppler ultrasonographic monitoring of both the right and left middle cerebral arteries was used to assess the adequacy of cerebral bihemispheric perfusion and to determine the differences in blood flow velocities throughout the procedure. RESULTS: Left common carotid artery cannulation was successful in all patients. All patients awoke from the operation, and none had cerebrovascular accidents. None died in the hospital, and complications related to carotid artery cannulation were not observed. None of the patients experienced postoperative paraplegia. In all patients transcranial Doppler monitoring indicated the absence of cerebral embolic phenomena throughout the entire procedure. Significant differences in middle cerebral artery flow velocities were observed at different phases of the procedures and between the right and left middle cerebral arteries during carotid cannulation and during selective cerebral perfusion. Nevertheless, the maximal drop of right middle cerebral artery blood velocity during selective perfusion through the left common carotid artery was within 50% of the left middle cerebral artery velocity, indicating adequate bihemispheric perfusion. CONCLUSIONS: In patients undergoing aortic operations through a left thoracotomy, extrathoracic left common carotid artery cannulation was a safe and effective means of providing proximal arterial inflow during cardiopulmonary bypass, which can be used to selectively perfuse the brain, as well as to prevent embolic phenomena in the arch vessels.     

Cannula malposition during antegrade cerebral perfusion for aortic surgery: role of cerebral oximetry

Purpose

To describe the use of cerebral oximetry to detect a lack of right cerebral perfusion resulting from a malpositioned catheter used for antegrade cerebral perfusion during deep hypothermic circulatory arrest (DHCA). The simple corrective surgical adjustment that followed averted a potentially serious complication.

Clinical features

A 57-yr-old male with a type-A aortic dissection undergoing DHCA required antegrade cerebral perfusion for cerebral protection. Catheters were placed accordingly in the left common carotid and brachiocephalic arteries. Whereas frontal cerebral oximetry immediately improved on the left, it did not improve on the right. It was immediately suspected that the tip of the brachiocephalic cannula had advanced into the right subclavian artery, thus depriving the right common carotid artery of blood flow. The problem resolved upon slight withdrawal of the cannula.

Conclusion

Vigilance in anesthesia should not stop during DHCA or cardiopulmonary bypass. Cerebral oximetry may provide important information leading to actions that improve brain protection. Vigilances proved important in this case where the cannula tip used for antegrade cerebral perfusion was advanced too far into the right subclavian artery.     

Successful repair of iatrogenic acute aortic dissection with cerebral malperfusion

We describe the successful treatment of a patient with iatrogenic acute aortic dissection including cerebral malperfusion as a complication of coronary artery surgery. After beginning cardiopulmonary bypass, a retrograde ascending aortic dissection associated with cerebral malperfusion was recognized. Systemic circulation was immediately arrested at 31 degrees C. After aortotomy, hypothermic selective antegrade cerebral perfusion was established. Replacement of the ascending aorta with coronary artery bypass grafting was performed without neurologic complications.     

An experience with simultaneous carotid endarterectomy and myocardial revascularization in a patient with calcified ascending aorta

We reported a 65-year-old male with the history of both cerebral and myocardial infarctions. Simultaneous carotid endarterectomy and myocardial revascularization (coronary artery bypass grafting = CABG) were performed. Ascending aorta was severely calcified. CABG was performed without aortic cross clamp under systemic moderate hypothermia and elective ventricular fibrillation. The wean off from extracorporeal circulation was successful. The postoperative course was uneventful. We recommend the simultaneous revascularization for the carotid and coronary artery obstructive diseases. CABG under ventricular fibrillation without aortic cross clamp was useful and unhazardous in patients presenting calcified ascending aorta.     

Single-staged operation for the patients with concomitant diseases of coronary and carotid arteries

The authors describe four cases with concomitant coronary and carotid severe stenosis operated by combined procedure. As the cerebral revascularization, carotid endarterectomy (CEA) was performed for three patients, while carotid artery bypass grafting was performed for the other one. In one patient with bilateral carotid stenosis, percutaneous transluminal stenting of the right internal carotid artery was performed one day before combined left CEA and coronary artery bypass grafting (CABG). Both perioperative myocardial infarction and neurological complication could be avoided in each case. When a CABG candidate also has significant extracranial carotid stenosis with clinical symptoms, combined cerebral revascularization and CABG is desirable.     

Simultaneous carotid endarterectomy and coronary revascularization

BACKGROUND: Combined cardiac operation and carotid endarterectomy using our technique is an acceptable approach to simultaneous correction of both carotid and cardiac disease. METHODS: From August 1989 to March 1998, 121 consecutive patients underwent combined operations. Of these patients, 112 had coronary artery bypass grafting and carotid endarterectomy, and 9 had coronary artery bypass grafting, carotid endarterectomy, and valve repair or replacement. All patients had a critical stenosis of 85% or more of the carotid artery. Mean age of the patients was 69.2 years; 80 patients were 65 years old or older. There were 88 men and 33 women. Notable risk factors included chronic obstructive pulmonary disease (19.8%), congestive heart failure (28%), preoperative myocardial infarction and unstable angina (66.9%). Of the patients, 20.7% had a stenosis of greater than 50% of the left main coronary artery. The technique used was correction of both the carotid and coronary lesions during a single aortic cross-clamp period using retrograde continuous blood cardioplegia for myocardial protection. Systemic hypothermia to 25 degrees C was used for cerebral protection. RESULTS: Mean cross-clamp time was 118 minutes. Seven patients (5.8%) sustained perioperative cerebrovascular accidents. Two patients had transient ischemic attacks. The procedure-related mortality rate was 5.8%. CONCLUSIONS: The described technique is a good method for simultaneous repair of coronary and carotid lesions in a high-risk group of patients with concomitant disease. We will continue to use it.     

Combined carotid and coronary artery disease

Stroke is a devastating complication of coronary artery bypass surgery. It increases the mortality and morbidity of the operation, and prolongs the length of hospital stay. Functional disability from the stroke may dramatically reduce the quality of life post-operatively, and some patients will require permanent institutional care. Although there are many causes of stroke extra-cerebral carotid stenosis is the most important predictor of stroke for patients undergoing coronary artery bypass grafting (CABG). If patients are identified before coronary intervention, they may benefit from treatment of their carotid disease. Carotid endarterectomy can be performed before or simultaneously with coronary artery bypass. However, carotid angioplasty with stenting and cerebral protection may offer a superior method to conventional surgery in this high-risk group of patients.     

"Internal cross-clamping" for symptomatic internal carotid artery thrombus. Report of two cases

Both carotid endarterectomy and carotid artery stent placement with filter embolic protection present a higher risk for patients with internal carotid artery (ICA) lesions containing intraluminal thrombus. Despite the risk associated with intervention, patients with symptomatic intraluminal thrombus who were enrolled in the North American Symptomatic Endarterectomy Trial did better with surgical than medical treatment. We describe the novel use of an endovascular "internal cross-clamping" technique in two patients with symptomatic intraluminal thrombus in the ICA. A 57-year-old woman presented with a history of multiple episodes of left upper-extremity numbness, mild dysarthria, and agraphia occurring over the previous 24 hours. Cranial magnetic resonance imaging revealed a scattered watershed infarction of the right hemisphere and a critical stenosis of the right ICA. An 81-year-old man awoke with hemiplegia and inability to follow commands after undergoing a complicated carotid endarterectomy. Computed tomographic perfusion imaging demonstrated an increased time to peak in the left middle cerebral territory, and emergent angiography demonstrated both intimal flaps and thrombus in the endarterectomy bed. The lesions in both patients were treated with endovascular stent placement using both proximal and distal flow occlusion--a functional "internal cross-clamping"--for embolic protection. To our knowledge, this is the first report of internal trapping and stent placement for symptomatic carotid stenosis containing intraluminal thrombus. This treatment strategy should be added to the armamentarium of endovascular surgeons in selected patients with symptomatic carotid intraluminal thrombus.     

Dilatation of the aneurysmal sac after total arch replacement

In our institution, total arch replacement for distal arch aneurysms is performed through a median sternotomy with antegrade selective cerebral perfusion. The distal anastomosis to the completely transected descending aorta is made through the aneurysmal sac. We report on three interesting cases presenting late dilatation of the aneurysmal sac due to collateral flow after total arch replacement.     

Antegrade selective cerebral perfusion during surgery of the thoracic aorta: risk analysis

Objective: To determine independent predictors of neurologic outcome and hospital mortality after surgery of the thoracic aorta using moderate hypothermic circulatory arrest and antegrade selective cerebral perfusion. Methods: Between November 1996 and June 2000, 96 consecutive patients (69 men, 27 women; mean age 63±10 years) underwent operations on the thoracic aorta with the aid of moderate hypothermic circulatory arrest and antegrade selective cerebral perfusion. Sixty-four patients were operated on electively (66.7%), 32 emergently (33.3%). Indications for surgery were: type A acute dissection in 30 patients (31.3%), chronic aneurysm in 66 (68.8%). Seventeen patients (17.7%) had undergone previous aortic/cardiac surgical procedures. The mean selective cerebral perfusion time was 52.2±31.9 min (range, 18–220 min). Preoperative, intraoperative, and postoperative factors were analyzed by univariate and multivariate analysis to identify predictors of hospital mortality and neurologic outcome. Results: There were no operative deaths; the hospital mortality rate was 11.5% (11/96). Stepwise logistic regression revealed preoperative renal dysfunction (P=0.021), type A acute dissection (P=0.053), coronary artery bypass grafting (P=0.058), post-operative pulmonary complications (P=0.000) and repeat thoracotomy for bleeding (P=0.027) as independent predictors of hospital mortality. One patient sustained a permanent neurologic deficit (1%). Transient neurologic deficit occurred in eight patients (8.3%). Coronary artery bypass grafting (P=0.013), and postoperative cardiac complications (P=0.049) were statistically associated with an increased risk of any (transient and permanent) neurologic dysfunction on univariate analysis. Stepwise logistic regression indicated coronary artery bypass grafting as independent factor for any neurologic dysfunction. Conclusion: This study confirmed that selective cerebral perfusion is an effective method of cerebral protection allowing complex thoracic aorta operations to be performed with low risk of hospital mortality and adverse neurologic outcome. We didn't find that the duration of selective cerebral perfusion time influence hospital mortality and any neurologic deficit.