Usefulness of antegrade selective cerebral perfusion during aortic arch operations

BACKGROUND: To evaluate the safety and usefulness of antegrade selective cerebral perfusion (SCP) during arch aneurysm or aortic dissection operations. METHODS: Between January 1986 and December 2001, 330 patients underwent aortic arch repair using SCP. Operations were performed with the aid of hypothermic extracorporeal circulation, SCP, and systemic circulatory arrest in most cases. In all, 89 patients (27%) were operated on for acute aortic dissection, 77 (23%) for chronic aortic dissection, and 164 (50%) for degenerative aneurysm. Total arch replacement using a branched graft was performed in 288 patients (94%). Mean SCP time was 86.2 +/- 28.5 minutes. RESULTS: The overall in-hospital mortality rate was 11.2% (falling to 3.2% in the 124 patients operated on between 1997 and 2001). Independent determinants of hospital mortality were pump time, renal/mesenteric ischemia, chronic renal failure, increasing age, period of operation, and nonuse of four-branched arch graft. The overall postoperative incidences of temporary and permanent neurologic dysfunction were 4.2% and 2.4%, respectively. There was no significant correlation between SCP time and in-hospital mortality or neurologic outcome. CONCLUSIONS: Selective cerebral perfusion is a reliable technique for cerebral protection and it facilitates complex and time-consuming total arch replacement.     

T-graft technique under antegrade cerebral perfusion for aortic arch aneurysm

We have devised a T-graft technique for selected extensive aortic arch replacement under antegrade cerebral perfusion. Under hypothermic circulatory arrest using antegrade cerebral perfusion, one graft was island-anastomosed to the supraaortic arteries. The other graft was anastomosed to the descending aorta. Proximal and distal grafts were then end-to-side anastomosed in a T-shape. During rewarming, the ascending aorta and proximal graft were anastomosed. The surgical field was good in the 6 patients included in this report. No perioperative deaths or serious complications were encountered. This procedure was effective for patients with extensive aortic arch aneurysm and relatively intact orifices of the supraaortic arteries.     

Total arch replacement using antegrade selective cerebral perfusion with right axillary artery perfusion.

OBJECTIVE: Right axillary artery (AxA) perfusion, which can prevent cerebral embolism caused by retrograde perfusion via the femoral artery (FA), was used for selective cerebral perfusion (SCP) as well as cardiopulmonary bypass (CPB) in aortic arch repair. We review the outcome of aortic arch surgery using SCP with right AxA perfusion to clarify its efficacy. METHOD: Between 1998 and 2002, 120 patients underwent aortic arch repair using SCP with right AxA perfusion. The mean age was 69+/-10 years. Aneurysms were atherosclerotic in 79, dissecting in 32, and others in nine patients. Twenty of them (16.7%) required emergency surgery. CPB was initiated with right AxA and FA perfusion, and following SCP was established using right AxA and left common carotid artery perfusion. RESULTS: With right AxA perfusion, hospital mortality was 5.8%. Multivariate analysis showed only ruptured aneurysm was an independent determinant for hospital mortality. Permanent neurological dysfunction developed in one patient (0.8%), while seven (5.8%) suffered from temporary one. In univariate analysis, SCP time, stenosis of the carotid arteries, past history of cerebrovascular events, and atherosclerotic aneurysm were not related to temporary neurological deficits CONCLUSION: Right AxA perfusion in conjunction with SCP is a safe and useful alternative for brain protection in total arch replacement.     

Total aortic arch grafting via median sternotomy using integrated antegrade cerebral perfusion

BACKGROUND: In aortic arch grafting, antegrade cerebral perfusion prolongs the safe time of arch exclusion. However, there are the problems of cerebral embolism and distribution of the cerebral perfusion. We describe and analyze mortality and cerebral complications in patients undergoing total arch grafting using our refined technique. METHODS: Between June 1994 and March 2002, 100 consecutive patients underwent total arch grafting through median sternotomy. There were 49 atherosclerotic aneurysms and 51 aortic dissections. Fifty-four patients were operated on an emergency basis because of rupture or acute type A dissection. We conducted total arch grafting using hypothermic antegrade cerebral perfusion from every cervical vessel. Carbon dioxide gas was added to the cerebral perfusion in order to inhibit the increase in the cerebral vascular resistance during hypothermic cerebral perfusion. RESULTS: Hospital mortality was 4%. The causes of death were dysarrhythmia (n = 1), mesenteric necrosis (n = 1), and preoperative cardiac arrest (n = 2). On univariate analysis, preoperative shock and concomitant cardiac procedures were risk factors for hospital death. The rate of postoperative neurologic damage was 5%. Two patients suffered from cerebral infarction. Temporary neurologic dysfunction occurred in 3 patients. On univariate analysis, emergency surgery was a risk factor for postoperative neurologic damage. On multivariate analysis, there was no significant independent predictor of hospital mortality and neurologic damage. Actuarial survival at 96 months was 66.4 +/- 9.1%, and freedom from aortic accidents (reoperation, rupture, and cholesterol embolism) was 74.9 +/- 7.9%. CONCLUSIONS: The early- and long-term results of total arch grafting using integrated antegrade cerebral perfusion were found to be satisfactory.     

Aortic arch replacement using a trifurcated graft and selective cerebral antegrade perfusion

BACKGROUND: Aortic arch aneurysm repair remains associated with considerable mortality and risk of cerebral complications. We present results of a technique utilizing a three-branched graft for arch replacement, deep hypothermic circulatory arrest (HCA), and selective antegrade cerebral perfusion (SCP). METHODS: Between March 2000 and November 2001, 22 patients (11 female) aged 40 to 77 years (mean 64 +/- 11.2) underwent arch replacement utilizing the trifurcated-graft technique. Serial anastomosis of the branched graft to individual cerebral vessels was carried out during HCA, followed by arch reconstruction during SCP through the graft. All 22 patients had surgery electively. Eight patients (36%) had undergone previous aortic surgery. In 19 patients, arch replacement was part of an elephant trunk procedure; 2 patients had Bentall operations and 1 had isolated arch replacement. Concomitant coronary artery bypass grafting was performed in 6 patients (27%). Mean HCA duration was 30 +/- 6 minutes at a mean temperature of 11.4 +/- 0.8 degrees C. Mean duration of SCP was 52 +/- 18 minutes. RESULTS: Adverse outcome--death before hospital discharge or permanent stroke or both--occurred in 2 patients (9%). Two patients experienced transient neurologic dysfunction (9%). Two patients (9%) developed renal failure requiring short-term hemodialysis and pulmonary complications occurred in 2 patients. CONCLUSIONS: Cerebral protection and prevention of atheroembolism remain challenges in aortic arch reconstruction. To reduce neurologic complications we developed an aortic arch reconstruction technique in which a trifurcated graft is anastomosed to the brachiocephalic vessels during HCA, reducing the risk of embolization while minimizing cerebral ischemia by permitting antegrade cerebral perfusion as arch repair is completed.     

Prospective comparative study of brain protection in total aortic arch replacement: deep hypothermic circulatory arrest with retrograde cerebral perfusion or selective antegrade cerebral perfusion

BACKGROUND: The purpose of this study was to compare the results of total aortic arch replacement using two different methods of brain protection, particularly with respect to neurologic outcome. METHODS: From June 1997, 60 consecutive patients who underwent total arch replacement through a midsternotomy were alternately allocated to one of two methods of brain protection: deep hypothermic circulatory arrest with retrograde cerebral perfusion (RCP: 30 patients) or with selective antegrade cerebral perfusion (SCP: 30 patients). Preoperative and postoperative (3 weeks) brain CT scan, neurological examination, and cognitive function tests were performed. Serum 100b protein was assayed before and after the cardiopulmonary bypass, as well as 24 hours and 48 hours after the operation. RESULTS: Hospital mortality occurred in 2 patients in the RCP group (6.6%) and 2 in the SCP group (6.6%). New strokes occurred in 1 (3.3%) of the RCP group and in 2 (6.6%) of the SCP group (p = 0.6). The incidence of transient brain dysfunction was significantly higher in the RCP group than in the SCP group (10, 33.3% vs 4, 13.3%, p = 0.05). Except in patients with strokes, S-100b values showed no significant differences in the two groups (RCP: SCP, prebypass 0.01+/-0.04: 0.05+/-0.16, postbypass 2.17+/-0.94: 1.97+/-1.00, 24 hours 0.61+/-0.36: 0.60+/-0.37, 48 hours 0.36+/-0.45: 0.46+/-0.40 microg/L, p = 0.7). There were no intergroup differences in the scores of memory decline (RCP 0.74+/-0.99; SCP 0.55+/-1.19, p = 0.6), orientation (RCP 1.11+/-1.29; SCP 0.50+/-0.76, p = 0.08), or intellectual function (RCP 1.21+/-1.27; SCP 1.05+/-1.15, p = 0.7). CONCLUSIONS: Both methods of brain protection for patients undergoing total arch replacement resulted in acceptable levels of mortality and morbidity. However, the prevalence of transient brain dysfunction was significantly higher in patients with the RCP.     

Noninvasive control of adequate cerebral oxygenation during low-flow antegrade selective cerebral perfusion on adults and infants in the aortic arch surgery

Abstract Real‐time readings of the regional oxygen saturation (rSO₂) using near‐infrared spectroscopy (NIRS) during the aortic arch surgery can provide an early detection of perfusion or oxygenation abnormalities. Background: Aortic arch repair techniques using low‐flow antegrade selective cerebral perfusion have been standardized to a certain degree. However, some of the often‐stated beneficial effects have never been proven. Especially, the existence of an adequate continuous flow in both cerebral hemispheres during the surgical procedure still remains unclear as the monitoring of an effective perfusion remains a nonstandardized technique. Methods: Seventeen patients underwent surgical reconstruction of the aortic arch due to aortic aneurysm surgery (adult group n = 8 patients) or of the hypoplastic aortic arch due to hypoplastic left heart syndrome (HLHS) or aortic coarctation (infant group n = 9 patients) under general anesthesia and mild hypothermia (adult group 28 °C; infant group 25 °C). Mean weights were 92.75 ± 14.00 kg and 4.29 ± 1.32 kg, and mean ages were 58.25 ± 10.19 years and 55.67 ± 51.11 days in the adult group and the infant group, respectively. The cerebral O₂ saturation measurement was performed by continuous plotting of the somatic reflectance oximetry of the frontal regional tissue on both cerebral hemispheres (rSO₂, INVOS^®; Somanetics Corporation, Troy, MI, USA). Results: During low‐flow antegrade perfusion via innominate artery, continuous plots with similar values of O₂ saturation (rSO₂) in both cerebral hemispheres were observed, whereas a decrease in the rSO₂ values below the desaturation threshold correlated with a displacement or an incorrect positioning of the arterial cannula in the right subclavian artery. Conclusions: Continuous monitorization of the cerebral O₂ saturation during aortic arch surgery in adults and infants is a feasible technique to control an adequate cannula positioning and to optimize clinical outcomes avoiding neurological complications related to cerebral malperfusion.     

Mortality and morbidity after total arch replacement using a branched arch graft with selective antegrade cerebral perfusion

BACKGROUND: The early outcome after aortic arch surgery has improved. However, some operative survivors have died as a result of postoperative problems soon after discharge. This study determines the factors affecting mortality within 1 year of total arch replacement. METHODS: Between July 1993 and November 2001, 103 patients (mean age 65 +/- 11 years, 26 women, 35 dissections) underwent total arch replacement through a median sternotomy using a branched arch graft with selective cerebral perfusion. Eighteen operations including 14 acute dissections were performed on an emergency basis. Concomitant procedures were root replacement in 5 patients, mitral valve replacement in 1, coronary artery bypass in 14, and open endovascular stent-graft in 9. The average time (minutes) for bypass, aortic cross-clamp, selective cerebral perfusion, and distal arrest were respectively 273 +/- 79, 163 +/- 54, 145 +/- 36, and 69 +/- 22. RESULTS: Mechanical heart support was necessary in 3 patients. Stroke occurred in 9 patients, transient neurologic dysfunction in 7, and paraplegia/paraparesis in 4. The only independent determinant for postoperative stroke was a history of stroke (odds ratio 16.3, 95% confidence interval: 2.8 to 93.8). Thirty-one patients required ventilator support for more than 5 days. Hemodialysis was needed in 5 patients. Sternal infection or mediastinitis occurred in 6 patients. The in-hospital mortality was 12% (12 of 103). The actuarial survival rate at 1 year was 83%, and was 67% at 5 years. For the 1-year mortality independent determinants were emergency surgery (odds ratio 5.3, 95% confidence interval: 1.6 to 17.9) and age 75 years or older (odds ratio 4.0, 95% confidence interval: 1.1 to 13.9). CONCLUSIONS: Total arch replacement using a branched arch graft with selective antegrade cerebral perfusion has a favorable 1-year mortality rate except for patients undergoing emergency surgery and for elderly patients.     

Arch repair with unilateral antegrade cerebral perfusion.

OBJECTIVE: Several antegrade cerebral perfusion techniques with differing neurological outcomes are employed for aortic arch repair. This study demonstrates the clinical results of aortic arch repair with unilateral cerebral perfusion via the right brachial artery. METHODS: Between January 1996 and March 2004, 181 patients underwent aortic arch repair via the right upper brachial artery with the use of low-flow (8-10 ml/kg per min) antegrade selective cerebral perfusion under moderate hypothermia (26 degrees C). Mean patient age was 58+/-12 years. Presenting pathologies were Stanford type A aortic dissection in 112, aneurysm of ascending and arch of aorta in 67, and isolated arch aneurysm in two patients. Ascending and/or partial arch replacement was performed in 90 patients and ascending and total arch replacement in 91 patients (including 27 with elephant trunk). In a subset of patients, renal and hepatic effects of ischemic insult were assessed. Free hemoglobin and lactate dehydrogenase levels were measured pre and postoperatively to identify hemolytic effects of brachial artery cannulation. RESULTS: Mean antegrade cerebral perfusion time was 36+/-27 min. Three patients with acute proximal dissection died due to cerebral complications. One patient had transient right hemiparesis. Total major neurological event rate was 2.2%. Brachial artery was able to carry full cardiopulmonary bypass flow with mild hemolysis. Renal and hepatic tests showed no deleterious effects of limited ischemia at moderate hypothermia. CONCLUSIONS: Arch repair with antegrade cerebral perfusion through right brachial artery has excellent neurological results, provides technical simplicity and optimal repair without time restraints, does not necessitate deep hypothermia and requires shorter CPB and operation times.     

Impact of retrograde cerebral perfusion on aortic arch aneurysm repair

OBJECTIVE: Protection of the brain is a primary concern in aortic arch surgery. Retrograde cerebral perfusion is a relatively new technique used for cerebral protection during profound hypothermic circulatory arrest. This study was designed to compare, retrospectively, the outcome of 109 patients undergoing aortic arch operation with and without the use of retrograde cerebral perfusion. METHODS: Fifty-five patients had profound hypothermic circulatory arrest alone, and 54 patients had supplemental cerebral protection with retrograde cerebral perfusion. Mean age was 61 +/- 13 years and 58 +/- 14 years, respectively (mean +/- standard deviation). Twenty-two preoperative and intraoperative characteristics, including age, sex, acuity, presence of aortic dissection, and aneurysm rupture, were similar in the 2 groups (P >.05). RESULTS: Mean circulatory arrest times (in minutes) were 30 +/- 19 in the group without retrograde cerebral perfusion and 33 +/- 19 in the group with retrograde cerebral perfusion, respectively. chi(2) Analysis revealed that patients operated on with the use of retrograde cerebral perfusion had significantly lower hospital mortality (15% vs 31%; P =.04) and in-hospital permanent neurologic complications (9% vs 27%; P =.01). Retrograde cerebral perfusion failed to reduce the prevalence of temporary neurologic dysfunction (17% vs 18%; P =.9). Stepwise multiple logistic regression revealed that extracorporeal circulation time, age, and lack of retrograde cerebral perfusion were statistically significant independent risk factors for hospital mortality. The same analysis revealed that lack of retrograde cerebral perfusion was the only significant independent risk factor for permanent neurologic dysfunction. CONCLUSION: Retrograde cerebral perfusion decreased the prevalence of permanent neurologic complications and the hospital mortality in patients undergoing aortic arch operations.