Preliminary results of intermittent retrograde cerebral perfusion during proximal aortic arch surgery

Objective: Continuous retrograde cerebral perfusion during aortic arch surgery is associated with cerebral edema. In this report, we describe the clinical use of a new type of intermittent retrograde cerebral perfusion.Subjects and Methods: Fourteen patients with a Stanford type A dissection were included in this study. With the usual method of retrograde cerebral perfusion, about 2,500 mL venous blood is drained from bicaval cannulae into a hard-shell reservoir, and oxygenated blood is perfused through the superior vena caval cannula. The flow rate is 300 mL/min. After about 15 min, retrograde perfusion is discontinued, and drainage from the bicaval cannulae is restarted. When a bloodless field is necessary, perfusion also is discontinued.Results: Two to seven cycles of intermittent retrograde cerebral perfusion were administered (average, 3.1±0.4, mean±SD). The total retrograde perfusion time was 36.0±1.9 min which was equivalent to 74.8% of the circulatory arrest time. No patient developed edema of the upper body. The time to wake-up was 3 to 14 h (average, 6.5±1.0h). No patient suffered any neurologic complications even though the time of circulatory arrest was greater than 60 min in four cases. Head magnetic resonance imaging or computed tomography was performed in 12 cases, and no evidence of hypoxic brain injury was detected.Conclusions: Our clinical experience using a moderate amount of intermittent retrograde cerebral perfusion is superior to continuous retrograde cerebral perfusion for protecting the brain during aortic arch surgery.     

Simple hypothermic retrograde cerebral perfusion during aortic arch surgery.

We have found that retrograde cerebral perfusion can be performed by simply elevating central venous pressure during aortic arch surgery. During hypothermia (15 degrees C) venous blood rich in oxygen perfuses the brain, while the lower half of the body is perfused with the descending aorta occluded. Fourteen cases of aortic arch aneurysm (11 males, 3 females) were treated by this method and evaluated. Median and lateral thoracotomies were performed in 6 and 8 cases, respectively. Cerebral circulatory arrest time was 65 +/- 14 min (32-93 min), and significant oxygen and lactate extraction were noted in the brain. Eleven cases showed no neurologic deficit, but loss of consciousness due to other causes occurred in 3. In conclusion, this method maintained the aerobic metabolism of the brain and protected it during prolonged cerebral circulatory arrest, simplifying the procedure and permitting both median and lateral approaches.     

Total aortic arch replacement under intermittent pressure-augmented retrograde cerebral perfusion

Kitahori, Kawata, Takamoto et al. described the effectiveness of a novel protocol for retrograde cerebral perfusion that included intermittent pressure augmentation for brain protection in a canine model. Based on their report, we applied this novel technique clinically. Although the duration of circulatory arrest with retrograde cerebral perfusion was long, the patient recovered consciousness soon after the operation and had no neurological deficit. Near-infrared oximetry showed recovery of intracranial blood oxygen saturation every time the pressure was augmented.     

Influence of retrograde cerebral perfusion during aortic arch procedures

BACKGROUND: Recent reports suggest dramatic improvement in outcome using retrograde cerebral perfusion (RCP) during operations on the arch; however, most investigators have compared contemporary results with historic controls. The purpose of this study was to determine the impact of RCP within the same patient population and time period. METHODS: From 1996 to 2000, 72 consecutive patients underwent an aortic arch procedure using hypothermic circulatory arrest (HCA) (31 acute dissection or rupture, 41 chronic dissection or aneurysm). Supplemental RCP was used in 36 patients, whereas 36 patients had HCA alone. The groups were similar in age, emergent status, and cardiopulmonary bypass time (p > 0.08), but HCA time was higher with RCP (40 +/- 15 minutes versus 29 +/- 14 minutes; p < 0.001). RESULTS: Operative mortality was 10% +/- 4% (+/- 70% confidence limit), and adverse outcomes (death or cerebrovascular accident) occurred in 14% +/- 4%, but there was no difference between HCA alone (8% +/- 5%, 14% +/- 6%) and HCA with RCP (11% +/- 5%, 14% +/- 6%) (p > 0.73). The incidence of transient neurologic dysfunction was also similar (HCA alone, 11% +/- 5%; HCA with RCP, 17% +/- 6%; p > 0.73). Multivariate risk factors for mortality included emergency operation and HCA time (p < 0.02). Risk factors for adverse outcome included emergency operation and atheromatous ascending aorta (p < 0.03). Risk factors for transient neurologic dysfunction included preexisting cerebrovascular disease and rewarming retrograde (femoral) rather than antegrade (through the graft) (p < 0.03). CONCLUSIONS: Supplemental RCP during HCA did not decrease mortality or neurologic complications. Retrograde rewarming through the femoral artery after completion of the distal anastomosis increased transient neurologic dysfunction. Therefore, RCP remains optional, but reperfusion should be antegrade to improve neurologic recovery.     

Simple hypothermic retrograde cerebral perfusion for brain protection during aortic arch surgery]

We have recently found that retrograde cerebral perfusion can be performed by simply elevating central venous pressure to 15 mmHg in the Trendelenburg position when the aortic arch is open during aortic arch surgery. During deep hypothermic (15 degrees C) perfusion of the lower half of the body with the descending aorta occluded, and with single cannulation of the right atrium for drainage, oxygen-saturated venous blood perfuses the brain retrogradely, supplying it with oxygen. This method renders clamping of the aortic arch and the arch vessels unnecessary. Eleven cases of aortic arch aneurysm (9 males, 2 females; 5 true aneurysms, 5 dissecting aneurysms, one combined aneurysm; mean age, 63 years) were operated using this technique, whose clinical significance was then evaluated. Median sternotomy was performed in 4 cases, left thoracotomy in 7. Patch replacement was performed in 2 cases and graft replacement in 9 cases (the proximal arch in 2, the whole arch in 2, the distal arch in 5). In two cases coronary artery bypass surgery using the internal thoracic artery was performed simultaneously via lateral thoracotomy. Operation time was 517 +/- 139 min, pump time was 211 +/- 34 min, cardiac arrest time was 84 +/- 34 min and the lowest rectal temperature was 15.7 +/- 1.1 degrees C. In the venous return, PO2 was 188 +/- 136 mmHg, and SO2 97.5 +/- 2.9%, the respective values in the retrogradely perfused blood in the aortic arch being 46 +/- 12 mmHg and 68.8 +/- 18.8%.(ABSTRACT TRUNCATED AT 250 WORDS)     

Simplified technique for retrograde cerebral perfusion during repair of distal aortic arch and proximal descending thoracic aorta

Lesions of distal aortic arch and proximal descending thoracic aorta require a posterolateral thoracotomy approach and total circulatory arrest. Retrograde cerebral perfusion through the superior vena cava is technically difficult in such situations. We describe a simplified technique for delivery of retrograde cerebral perfusion through the left internal jugular vein.     

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.     

Medium-term results after surgery for aortic arch aneurysm with hypothermic cerebral perfusion

We have used two techniques of hypothermic cerebral perfusion (CP) for the surgical treatment of aortic arch aneurysm in the last 10 years. Between March 1985 and December 1993, 83 patients underwent surgery for aortic arch aneurysm. Fifty-one cases had aortic dissection (AD) in the transverse arch and/or its branches, and 32 cases showed true aneurysm (TA) of the aortic arch. In those 83 patients, 37 cases received antegrade CP and 46 cases underwent retrograde CP. Surgical results were compared among the groups by Kaplan-Meier actuarial method and Cox-Mantel statistical analysis. The early mortality after surgery for aortic arch aneurysm was 11.8% in the AD group and 21.9% in the TA group. The early mortality was 21.6% with antegrade CP and 10.9% with retrograde CP. The 6-year actuarial survival rate was 71.7% in the TA group and 67.1% in the AD group. In the AD group, the 3-year survival rate was 93.9% with retrograde CP and 61.1% with antegrade CP (P < 0.005). In the TA group, the 3-year survival rate was similar for antegrade CP (73.3%) and retrograde CP (69.2%). These results suggest that current surgical results of aortic arch aneurysm with hypothermic CP are acceptable and the retrograde CP technique might be recommended, especially for surgery of aortic arch aneurysm with AD.     

Deep hypothermic systemic circulatory arrest and continuous retrograde cerebral perfusion for surgery of aortic arch aneurysm.

From 1987 to February 1991, we have repaired or replaced the aortic arch in ten patients using deep hypothermic systemic circulatory arrest with continuous retrograde cerebral perfusion (CRCP). CRCP can be implemented using the bypass connecting the arterial and venous lines of the extracorporeal circuit to reverse the flow into the superior vena cava cannula after induction of circulatory arrest. CRCP flow required to maintain an internal jugular vein pressure of 20 mmHg ranged from 100 to 500 ml/min. After completion of suturing of the aortic arch graft, air is evacuated retrogradely from the open arch vessels prior to reestablishing the usual arterial return. Two patients died, one from sepsis and the other from liver cirrhosis 1 month postoperatively. CRCP times ranged from 11 to 56 min, and minimal nasopharyngeal temperatures ranged from 16 degrees to 18 degrees C. The difference in oxygen content between the perfused blood and the blood draining from the arch vessels during CRCP most likely reflected the steady-state metabolism of the brain during the deep hypothermic state. This technique offers advantages including the need for dissecting and clamping the arch branches, providing sufficient metabolic support to the brain during deep hypothermia, and eliminating embolism of particulate debris from the aortic arch.     

Neuropsychometric outcome following aortic arch surgery: a prospective randomized trial of retrograde cerebral perfusion

BACKGROUND: Aortic surgery requiring hypothermic circulatory arrest is associated with a high incidence of brain injury. However, knowledge of neuropsychometric outcome is limited. Retrograde cerebral perfusion has become a popular adjunctive technique to hypothermic circulatory arrest. The aim of this study was to assess neuropsychometric outcome and compare the 2 techniques. METHODS: In a prospective randomized trial, 38 patients requiring elective aortic arch surgery were allocated to either hypothermic circulatory arrest plus retrograde cerebral perfusion or hypothermic circulatory arrest alone. Neuropsychometric testing was performed preoperatively, and at 6 weeks and 12 to 24 weeks postoperatively. Deficit was defined as a 20% decline in 2 tests or more. Standardized Z scores were calculated for each patient and test. Eighteen patients underwent hypothermic circulatory arrest and 20 patients underwent hypothermic circulatory arrest plus retrograde cerebral perfusion. The mean cardiopulmonary bypass, hypothermic circulatory arrest, and retrograde cerebral perfusion durations were 169, 30, and 25 minutes, respectively. RESULTS: There were 2 deaths and 2 neurological deficits. At 6 weeks postoperatively, 77% of the hypothermic circulatory arrest group and 93% of the hypothermic circulatory arrest plus retrograde cerebral perfusion group had a deficit (P =.22). At 12 weeks this was reduced to 55% and 56%, respectively (P =.93). There was a worse total Z test score in the hypothermic circulatory arrest plus retrograde cerebral perfusion group at 12 weeks (P =.05). Neuropsychometric change did not correlate with hypothermic circulatory arrest duration, presence of aortic atheroma, cannulation technique, or procedure. CONCLUSIONS: Hypothermic circulatory arrest plus/minus retrograde cerebral perfusion is associated with a high incidence of neuropsychometric change despite ostensibly normal clinical outcomes and apparently safe arrest duration. Retrograde cerebral perfusion did not improve outcome in this small study.     

Reoperation for interrupted aortic arch with the use of retrograde cerebral perfusion.

We treated 2 patients with recurrent coarctation after repair of interrupted aortic arch. Because they had been operated on with the use of vascular prostheses, severe scarring was considered prohibitive for safe dissection. We successfully carried out anatomic repair with the use of retrograde cerebral perfusion through a left thoracotomy in both cases.     

Simple hypothermic retrograde cerebral perfusion during aortic arch replacement. A preliminary report on two successful cases.

We recently found that hypothermic retrograde cerebral perfusion can be performed by simply elevating the central venous pressure in Trendelenburg's position while the aortic arch is open. In this technique, with an occlusion balloon in the descending aorta, deep hypothermic perfusion of the lower half of the body is performed as oxygen-rich venous blood supplies the brain. Two successful cases are reported: one of dissecting aortic aneurysm, DeBakey type II, with a true aortic arch aneurysm, in a 53-year-old woman, and one of acute aortic dissection, DeBakey type I, in a 53-year-old man. With the brain under retrograde perfusion at a rectal temperature of 15 degrees C and a central venous pressure of 15 mm Hg, replacement of the ascending to the descending aorta in the former case and to the proximal aortic arch in the latter case was successful. Cerebral circulatory arrest times were 81 and 65 minutes, respectively. No neurologic deficit was found postoperatively. It is suggested that this simple technique protected the brain for a long period of cerebral circulatory arrest during the aortic arch operation by supplying it with oxygen and simplifying the operative procedure.     

Early and long-term results of surgery for aortic arch aneurysms using selective cerebral perfusion

OBJECTIVE: We report our operative technique for atherosclerotic arch aneurysms and early and long term results of the surgery. METHODS: Between April 1992 and December 2001, 80 consecutive patients underwent operation for atherosclerotic arch aneurysms. Their mean age was 70 +/- 7 years. Sixty-six (82.5%) patients were operated on electively. All operations were performed under median sternotomy using hypothermic circulatory arrest and selective antegrade cerebral perfusion. Total arch replacement was performed in 66 cases, proximal hemiarch replacement in 4 cases, distal arch replacement using stent graft implantation via aortic arch incision in 8 cases, and patch angioplasty in 2 cases. In 9 of these patients in whom mobile arch atheroma was revealed by intraoperative epiaortic ultrasonography, isolation technique was employed to avoid embolic stroke. RESULTS: Overall in-hospital mortality was 10.0% (8 of 80 patients). Postoperative temporary neurologic dysfunction was 7.5%, and stroke rate was 5.0%. The 3-year, and 5-year actuarial survival rate including hospital death was 79.3% and 75.3% respectively. The 3-year, and 5-year cardiovascular event free survival rate was 68.3% and 60.0% respectively. CONCLUSION: The early and long-term results of surgery for atherosclerotic arch aneurysms were acceptable. Selective cerebral perfusion is an effective brain protective adjunct.     

The methodologies of hypothermic circulatory arrest and of antegrade and retrograde cerebral perfusion for aortic arch surgery

In spite of recent advances in thoracic aortic surgery, postoperative neurological injury still remains the main cause of mortality and morbidity after aortic arch operation. The use of cardiopulmonary bypass (CPB) and hypothermic circulatory arrest, temporary interruption of brain circulation, transient cerebral hypoperfusion, and manipulations on the frequently atheromatic aorta all produce neurological damages. The basic established techniques and perfusion strategies during aortic arch replacement number three: hypothermic circulatory arrest (HCA), antegrade cerebral perfusion (ACP), and retrograde cerebral perfusion (RCP). During the past decade and after several experimental studies, RCP lost its previous place in the armamentarium of brain protection, giving it up to ACP as a major method of brain perfusion during HCA. HCA should be applied at a temperature of asymptotically equal to 20 degrees C with long-lasting cooling and rewarming and should not exceed by itself the time of 20-25 min. RCP does not seem to prolong safe brain-ischemia time beyond 30 min, but it appears to enhance cerebral hypothermia by its massive concentration inside the brain vein sinuses. HCA combined with ACP, however, could prolong safe brain-ischemia time up to 80 min. Cold ACP at 10 degrees -13 degrees C should be initially applied through the right subclavian or axillary artery and continued bihemispherically through the left common carotid artery at first and later the anastomosed graft, with a mean perfusion pressure of 40-70 mm Hg. The safety of temporary perfusion is being confirmed by the meticulous monitoring of brain perfusion through internal jugular bulb O2 saturation, electroencephalogram, and transcranial comparative Doppler velocity of the middle cerebral arteries.     

Long-term comparison of aortic arch replacement with or without elephant trunk procedure via retrograde cerebral perfusion for aortic arch dissection.

OBJECTIVE: The aim of this study is to investigate the effects of the duration of retrograde cerebral perfusion (RCP) in patients with aortic arch dissection. METHODS: Between 1993 and December 2000, 56 patients were operated on for aortic arch dissection. Elephant trunk procedure was performed in 28 patients (Group A) and semiarcus replacement in 28 patients (Group B). Type I dissection (P=0.003), chronic ethiology (P=0.006), medial degeneration (P<0.001), and preoperative hemodynamic instability (P=0.004) were observed significantly more in Group A. In both groups RCP was used for cerebral protection. RESULTS: Hospital mortality was higher in Group A than Group B (32.1% versus 7.1%; P=0.015). Late mortality was observed only in Group A (10.5%; P=0.049). Actuarial survival was 55.1+/-11.55% in Group A and 91.67+/-5.64% in Group B at 5 yr (P=0.0113), while cumulative survival for all patients was 78.38+/-5.77% at 5 yr. RCP time was longer in Group A (62.7+/-16.8 versus 34.2+/-19.5 min; P<0.001). Forward stepwise logistic regression analysis showed that chronic obstructive pulmonary disease (P=0.014) and renal insufficiency (P=0.004) were significantly predictors for hospital mortality, whereas elephant trunk (P=0.052) and RCP (>60 min) (P=0.175) did not increase early mortality. Only hemodynamic instability was significantly (P=0.006) predictors for late mortality. CONCLUSIONS: Preoperative severity of dissection, hemodynamic instability or organ dysfunctions impair early or late outcome. Elephant trunk technique with increased RCP time do not increase early or late mortality. To shorten RCP time (<60-65 min) can improve surgical results.     

Results of aortic arch repair with hypothermic circulatory arrest and retrograde cerebral perfusion

BACKGROUND: Repair of aortic arch pathology is reliably performed with hypothermic circulatory arrest, but the best method of brain protection is controversial. METHODS: We reviewed a consecutive series of 67 patients who had aortic arch repair with hypothermic circulatory arrest. Retrograde perfusion of arterial blood into the superior vena cava (SVC) during systemic arrest was used in 87%. Average age was 65 years. Acute dissection was present in 25%. Average circulatory arrest time was 37 minutes, and average temperature 17.7 degrees C. RESULTS: Hospital mortality was 1.5%. Strokes occurred in 4.5%. Temporary neurological dysfunction occurred in 16%. Multivariate logistic regression analysis showed that acute dissection was the only independent predictor of the combined risk of stroke and temporary neurological dysfunction (odds ratio 8.5). Duration of circulatory arrest and patient age were not risk factors for adverse neurological outcome. CONCLUSION: Continuous arterial perfusion of the SVC during hypothermic circulatory arrest provides excellent cerebral protection for aortic arch repair. Acute dissection is an independent risk factor for adverse neurological outcome. Arrest time is not a predictor of neurological dysfunction.     

Comparison of neurocognitive results after coronary artery bypass grafting and thoracic aortic surgery using retrograde cerebral perfusion.

OBJECTIVE: Retrograde cerebral perfusion (RCP) is used as an adjunctive method to hypothermic circulatory arrest to enhance cerebral protection in patients undergoing thoracic aortic surgery. It remains unclear whether RCP provides improved neurological and neuropsychological outcome. METHODS: Forty-six patients undergoing thoracic aortic surgery using RCP, and 28 undergoing coronary artery bypass grafting (CABG; n = 28) with CPB, were enrolled in the study. Patients receiving RCP were subdivided into two groups, those with less than 60 min of RCP (S-RCP; n = 27) and with 60 min or more (L-RCP; n = 19). The patients' neurocognitive state was assessed by the revised Wechsler Adult Intelligence Scale a few days before operation, at 2-3 weeks and 4-6 months after operation. RESULTS: There were no stroke, seizure, and hospital mortality in either group. Significant decline between baseline and early scores were seen in three subtests (digit span, arithmetic, and picture completion) for S-RCP and four (digit span, arithmetic, picture completion, and picture arrangement) for L-RCP. Significant decline between baseline and late scores were seen in one subtest (arithmetic) for S-RCP, four (digit span, arithmetic, picture completion, and picture arrangement) for L-RCP, and one (object assembly) for CABG. The mean change of scores for one late test (digit symbol) was significantly lower in S-RCP than in CABG. The mean change of scores for three early tests (digit span, vocabulary, and picture arrangement) and four late tests (information, digit span, picture completion, and picture arrangement) were significantly lower in L-RCP than in CABG. Stepwise logistic regression analysis disclosed that, after considering the other variables, significant difference in test score changes were observed between CABG and L-RCP for two early tests (picture completion and digit symbol) as well as for three late tests (digit span, similarities, and picture completion). None of test score changes showed significant difference between CABG and S-RCP. CONCLUSIONS: The neurocognitive outcome in patients undergoing RCP less than 60 min were comparable with patients undergoing CABG without circulatory arrest. Prolonged RCP of 60 min or more in patients undergoing surgery of the thoracic aorta was associated with postoperative neurocognitive impairment.     

Antegrade versus retrograde cerebral perfusion in relation to postoperative complications following aortic arch surgery for acute aortic dissection type A

Abstract   Background: Aortic arch surgery is impossible without the temporary interruption of brain perfusion and therefore is associated with high incidence of neurologic injury. The deep hypothermic circulatory arrest (HCA), in combination with antegrade or retrograde cerebral perfusion (RCP), is a well-established method of brain protection in aortic arch surgery. In this retrospective study, we compare the two methods of brain perfusion. Materials and Methods: From 1998 to 2006, 48 consecutive patients were urgently operated for acute type A aortic dissection and underwent arch replacement under deep hypothermic circulatory arrest (DHCA). All distal anastomoses were performed with open aorta, and the arch was replaced totally in 15 cases and partially in the remaining 33 cases. Our patient cohort is divided into those protected with antegrade cerebral perfusion (ACP) (group A, n = 23) and those protected with RCP (group B, n = 25). Results: No significant difference was found between groups A and B with respect to cardiopulmonary bypass-time, brain-ischemia time, cerebral-perfusion time, permanent neurologic dysfunction, and mortality. The incidence of temporary neurologic dysfunction was 16.0% for group A and 43.50% for group B (p = 0.04). The mean extubation time was 3.39 ± 1.40 days for group A and 4.96 ± 1.83 days for group B (p = 0.0018). The mean ICU-stay was 4.4 ± 2.3 days for group A and 6.9 ± 2.84 days for group B (p = 0.0017). The hospital-stay was 14.38 ± 4.06 days for group A and 19.65 ± 6.91 days for group B (p = 0.0026). Conclusion: The antegrade perfusion seems to be related with significantly lower incidence of temporary neurological complications, earlier extubation, shorter ICU-stay, and hospitalization, and hence lower total cost.