Similar Cerebral Protective Effectiveness of Antegrade and Retrograde Cerebral Perfusion During Deep Hypothermic Circulatory Arrest in Aortic Surgery: A Meta‐Analysis of 7023 Patients

In aortic arch surgery, deep hypothermic circulatory arrest (DHCA) combined with cerebral perfusion is employed worldwide as a routine practice. Even though antegrade cerebral perfusion (ACP) is more widely used than retrograde cerebral perfusion (RCP), the difference in benefit and risk between ACP and RCP during DHCA is uncertain. The purpose of this meta‐analysis is to compare neurologic outcomes and early mortality between ACP and RCP in patients who underwent aortic surgery during DHCA. PubMed, EMBASE, and the Cochrane Library were searched using the key words “antegrade,” “retrograde,” “cerebral perfusion,” “cardiopulmonary bypass,” “extracorporeal circulation,” and “cardiac surgery” for studies reporting on clinical endpoints including early mortality, stroke, temporary neurologic dysfunction (TND), and permanent neurologic dysfunction (PND) in aortic surgery requiring DHCA with ACP or RCP. Heterogeneity was analyzed with the Cochrane Q statistic and I² statistic. Publication bias was tested with Begg's funnel plot and Egger's test. Thirty‐four studies were included in this meta‐analysis, with 4262 patients undergoing DHCA + ACP and 2761 undergoing DHCA + RCP. The overall pooled relative risk for TND was 0.722 (95% CI = [0.579, 0.900]), and the z‐score for overall effect was 2.9 (P = 0.004). There was low heterogeneity (I² = 18.7%). The analysis showed that patients undergoing DHCA + ACP had better outcomes than those undergoing DHCA + RCP in terms of TND, while there were no significant differences between groups in terms of PND, stroke, and early mortality. This meta‐analysis indicates that DHCA + ACP has an advantage over DHCA + RCP in terms of TND, while the two methods show similar results in terms of PND, early mortality, and stroke.     

升主动脉和弓部动脉瘤的外科治疗

目的：总结升主动脉和弓部动脉瘤手术治疗经验，以期进一步提高手术疗效。方法：自2000年7月至2002年5月应用深低温停循环（DHCA）和上腔静脉逆行脑灌注（RCP）技术手术治疗升主动脉和弓部动脉瘤20例，其中急症手术5例。施行全弓置换术2例，全弓置换和象鼻手术3例，半弓置换术15例。同期行Bentall手术8例，升主动脉置换术或同时行主动脉瓣置换术12例，冠状动脉旁路移植术1例。结果：术后早期死亡1例，短时间浅昏迷1例，呼吸功能不全2例，肾功能不全2例，无晚期死亡。结论：DHCA和RCP技术是手术治疗升主动脉和弓部瘤的安全、有效方法，急性A型夹层动脉瘤的手术方式取决于内膜破裂口的位置；正确掌握DHCA和RCP技术，手术方式和手术技术、围术期处理是提高手术疗效的关键因素。     

A successful repair of intraoperative retrograde type A aortic dissection in a patient with aortic regurgitation and ascending aortic aneurysm

The patient was a 67-year-old male with aortic regurgitation and ascending aortic aneurysm. We noticed the type A retrograde aortic dissection occurring from the cannulation site through the right femoral artery. We discontinued cardio-pulmonary bypass immediately, and established selective cerebral perfusion (SCP) eleven minutes after retrograde cerebral perfusion (RCP). We underwent simultaneous aortic valve replacement and ascending and arch graft replacement with an aid of SCP combined with RCP and systemic low flow perfusion. Postoperative course was satisfactory, although patient had a transient neurologic deficit. Intraoperative aortic dissection is a rare but potentially fatal complication. RCP may be a simple and useful method in emergency operation for intraoperative retrograde type A aortic dissection to avoid serious cerebral damage.     

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.     

Clinical application of retrograde cerebral perfusion for brain protection during surgery of ascending aortic aneurysm--a report of 50 cases

This study was designed to discuss the effects on the brain by different protective methods in ascending aortic aneurysm surgery retrospectively. Two hundred seventy-one surgeries of ascending aortic aneurysm have been done in the past 15 years. There were 65 patients with a dissecting aneurysm of the aortic arch or right arch. To protect the brain, deep hypothermic circulatory arrest (DHCA) combined with retrograde cerebral perfusion (RCP) through superior vena cava (N = 50) and simple DHCA (N = 15) were used during the procedure. Blood samples for lactic acid level from the jugular vein were compared in both groups. Perfusion blood distribution and oxygen content difference between the perfused blood and returned blood were measured in 5 and 10 of RCP patients, respectively. The DHCA time was 35.86 +/- 18.81 min (10 approximately 63 min) and DHCA + RCP time was 45.5 +/- 17.21 min (16 approximately 81 min). The resuscitation time was 7.11 +/- 1.59 h (4.4 - 9.4 h) in DHCA versus 5.43 +/- 2.15 h (2 approximately 9 h) in RCP patients. The operation death rate was 3/15 in DHCA group and 1/50 in RCP patients. Central nervous complication occurred in 3/12 of DHCA patients and 1/49 of RCP patients (p < .01). The overall survival rate was 96% (RCP) versus 67% (DHCA); the central nervous system dysfunction was 20% in DHCA versus 2% in RCP (p < .001). The blood lactic acid level increased significantly after reperfusion in DHCA than that in RCP. The measurement of blood distribution indicated that approximately 2Q% of the perfused blood returned from arch vessels. The difference of oxygen content between perfused and returned blood showed that the oxygen uptake was adequate in RCP group. The application of RCP can prolong the safety duration of circulation arrest. Continuous cerebral perfusion may maintain the brain at a cooler temperature and flush out particulate and air emboli while open anastomosis of the aortic arch to the prosthesis can be safely performed. Therefore, RCP is a preferable method for brain protection in our clinical practices.     

主动脉弓部手术75例

目的 总结主动脉弓部手术的方法和临床经验。方法75例弓部手术中74例采用深低温停循环（DHcA）技术，其中54例脑保护采用上腔静脉逆灌（RCP），20例采用右腋动脉顺灌（SCP）；仅1例在中度低温体外循环下行局部切除吻合。升主动脉和半弓置换53例，其中同期行降主动脉腔内支架植入术11例，弓部内膜破口修补6例，降主动脉近端内膜破口修补3例；升主动脉和全弓置换20例，其中同期行传统象鼻手术12例，降主动脉腔内支架植入4例；单纯弓部瘤切除缝合及弓部置换各1例。同期手术包括17例Bentall手术，12例AVR，3例Cabrol手术，5例二尖瓣成形术，9例主动脉瓣悬吊成形术等。DHCA9～120min，平均42．3min。结果手术死亡5例，死亡率6．7％。主要并发症为呼吸功能不全11例，肾功能不全7例，一过性精神异常9例。结论DHCA＋RCP及DHCA＋SCP技术均是主动脉弓部手术的有效方法，但后者更适用于复杂的弓部手术；手术范围和方式取决于病变性质和范围，术前状况和手术技术是影响手术效果的决定因素。     

经上腔静脉逆行灌注脑保护在主动脉瘤手术中的应用

目的　探讨在主动脉瘤手术中应用经上腔静脉逆行灌注的脑保护效果。　方法　 65例主动脉瘤患者分 2组 ,15例采用深低温停循环 (DHCA) ,5 0例经上腔静脉逆行灌注 (RCP)进行脑保护。术中比较 2组患者不同时间颈内静脉的血乳酸含量 ,对部分RCP患者测定了灌注血和回流血的流量分布 ,以及灌注血和回流血的氧含量。　结果　DHCA组停循环时间为 10 0～ 63 0min ,平均(3 5 9± 18 8)min ;RCP组为 16 0～ 81 0min ,平均 (45 5± 17 2 )min。术后至清醒时间DHCA组为4 4～ 9 4h ,平均 (7 1± 1 6)h ;RCP组 2 0～ 9 0h ,平均 (5 4± 2 2 )h。DHCA组手术死亡 3例 ,RCP组死亡 1例 ;术后神经系统并发症DHCA组 3例 (死亡 2例 ,成活 1例 ) ,RCP组 1例 (存活 )。手术总成功率和神经系统并发症发生率RCP组分别为 96%和 2 % ,DHCA组为 67%和 2 0 % (P <0 0 5 )。RCP组再灌注期间颈内静脉血乳酸含量增高幅度低于DHCA组 [(4 4± 0 6)mmol/Lvs (6 2± 0 9)mmol/L ,P <0 0 1],经头臂和下腔静脉血流量测定显示约 2 0 %血液经头臂动脉回流 ,灌注血和回流血氧差9 0 0～ 13 67ml/L ,证实RCP期间脑组织有氧利用。　结论　在主动脉瘤手术中 ,应用RCP可以延长停循环的安全时限 ,是可行的脑保护方法     

Cardiopulmonary bypass for thoracic aortic aneurysm: a report on 488 cases

Our objective was to investigate different cardiopulmonary bypass (CPB) techniques for thoracic aortic aneurysm retrospectively. Four hundred and eighty-eight patients with thoracic aortic aneurysm received surgical treatment. Total CPB was used routinely in 331 cases with ascending aortic aneurysm. When the aneurysm expanded to the aortic arch, brain protection was executed by adopting deep hypothermia circulatory arrest (DHCA) or DHCA combined with retrograde cerebral perfusion (RCP). Selected cerebral perfusion via carotid artery was used in three cases and separated upper and lower body perfusion in five cases. Left heart bypass was adopted for the surgeries of 157 cases with descending aortic aneurysm. In two of the cases, ventricular defibrillation could not be achieved, and then bypass was altered to separated upper and lower body perfusion to acquire satisfactory outcome. In the ascending aortic aneurysm group, DHCA time in the 17 patients was 10-63 minutes (mean 35.58 +/- 18.81 min), and DHCA +/- RCP time in 61 patients was 16-81 minutes (mean 43.43 +/- 17.91 min). Total mortality of aortic aneurysm surgery requiring full CPB was 5.4% (18/331), in which eight patients died in emergency operations. The total mortality of emergency operation was 11.9% (8/67). In the descending aortic aneurysm group, time of left heart bypass was 125.56 +/- 57.28 min, and the total mortality was 7% (11 of 157 patients). Three patients developed postoperative paraplegia. Techniques for extracorporeal circulation for surgery of the aorta are dependent on the nature of the disease and require a flexible approach to meet the specific anatomical challenge. The ability to alter the perfusion circuit to meet unexpected situations should be anticipated and planned for. In this series, we have varied our approach to perfusion techniques as required with acceptable outcome data as compared to the international literature.     

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.     

A retrospective comparative study of deep hypothermic circulatory arrest, retrograde, and antegrade cerebral perfusion in aortic arch surgery.

OBJECTIVE: Despite theoretical advantages of antegrade (ACP) and retrograde cerebral perfusion (RCP) in addition to deep hypothermic arrest (DHA) in aortic arch surgery, there is still controversy about the best method of cerebral protection. We reviewed our experience with neurological outcome after aortic arch repair over the last five years. METHODS: Sixty-two patients undergoing aortic arch repair were reviewed. Five patients (8.1%) had Marfan's syndrome, 11 (17.7%) had previous cardiac operations, and 13 (21.0%) also received coronary bypass grafting (CABG). The extent of arch replacement was proximal level in 40 (64.5%), distal level in 18 (29.0%), and total in 13 (21.0%). The method of cerebral protection was DHA alone in 14 patients, DHA with RCP in 23, and DHA with ACP in 25. Pre-, intra-, and postoperative variables in the three categories of cerebral protection were compared. Specifically, the independent predictors of mortality, stroke, and temporary neurological dysfunction (TND) were examined. RESULTS: Overall hospital mortality was 5 (8.0%). Stroke occurred in 4 patients (6.4%), and TND in 5 (8.0%). There were no significant differences among the groups in mortality or neurological dysfunction. Total brain exclusion time (TBET) was significantly longer in ACP (DHA, 25.2+/-12.0 min; ACP, 61.8+/-44.1 min; RCP, 36.4+/-20.5 min; p=0.023). Multivariate analysis showed a trend for TBET of longer than 90 minutes as a predictor of stroke (p=0.06; odds ratio, 7.9). The actuarial survival rate was 88.7% at five years (DHA, 85.7%; ACP, 80.0%; RCP, 100%; no significant difference). CONCLUSIONS: Despite more complicated arch repairs requiring a significantly longer cerebral exclusion time which were performed in the group receiving ACP, there was no significant increase in stroke or death rates. Increasing confidence in the ability of ACP has led us to perform the most appropriate arch repair without compromising the extent of replacement for fear of exceeding the "safe" period of circulatory arrest.     

Hemodynamic performance of stented and stentless aortic bioprostheses

BACKGROUND: Acute type A aortic dissection is a surgical emergency still associated with high postoperative complications. The aim of this study was to investigate factors for hospital mortality and neurologic deficit in patients undergoing emergency operation for acute type A aortic dissection. METHODS: Eighty-five consecutive patients (age range, 20 to 82 years) operated on for acute type A aortic dissection over a 6-year period were evaluated. Univariate and stepwise multiple logistic regression analyses were conducted among 32 perioperative variables. RESULTS: All patients underwent surgical procedures under deep hypothermic circulatory arrest. Antegrade or retrograde cerebral perfusion was used in 23 patients (27.1%) and 18 patients (21.2%), respectively. Forty-three patients underwent arch/hemiarch replacement and the ascending aorta was replaced in 42 patients. Overall mortality rate was 25.9% (22 of 85 patients). Multiple logistic regression analysis showed that lack of cerebral perfusion (p = 0.021) and postoperative renal failure (p = 0.006) were the best predictors for hospital death. Twenty-one patients (24.7%) experienced neurologic accidents. The risk factor for postoperative neurologic complication was lack of cerebral perfusion (p = 0.013). Hospital mortality was 13% (3 of 23 patients) and 16.7% (3 of 18 patients) in the antegrade and retrograde cerebral perfusion groups (p > 0.05) and neurologic deficit was 13% (3 of 23 patients) and 11.1% (2 of 18 patients), respectively (p > 0.05). CONCLUSIONS: Hospital mortality and neurologic complications in patients undergoing emergent operation for acute type A aortic dissection were reduced when cerebral perfusion was used with deep hypothermic circulatory arrest.     

Hypothermic circulatory arrest does not increase the risk of ascending thoracic aortic aneurysm resection.

OBJECTIVE: The purpose of this study was to investigate the safety and efficacy of a period of deep hypothermic circulatory arrest (DHCA) during elective replacement of the ascending thoracic aorta. SUMMARY BACKGROUND DATA: DHCA has been implemented in ascending thoracic aortic aneurysm resection whenever the anatomy or pathology of the aorta or arch vessels prevents safe or adequate cross-clamping. Profound hypothermia and retrograde cerebral perfusion have been shown to be neurologically protective during ascending aortic replacement under circulatory arrest. METHODS: The authors conducted a retrospective analysis of 91 consecutive patients who underwent repair of chronic ascending thoracic aortic aneurysms from 1986 to present. The authors hypothesized that patients undergoing DHCA with or without retrograde cerebral perfusion during aneurysm repair were at no greater operative risk than patients who received aneurysm resection while on standard cardiopulmonary bypass. RESULTS: There were no significant differences in hospital mortality, stroke rate, or operative morbidity between patients repaired on DHCA when compared to those repaired on cardiopulmonary bypass. CONCLUSIONS: DHCA with or without retrograde cerebral perfusion does not result in increased morbidity or mortality during the resection of ascending thoracic aortic aneurysms. In fact, this technique may prevent damage to the arch vessels in select cases and avoid the possible complications associated with cross-clamping a friable or atherosclerotic aorta.     

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.     

DeBakeyⅠ型主动脉夹层术中双侧脑灌注脑保护的体会

目的 总结DeBakeyⅠ型主动脉夹层在深低温停循环选择性脑保护下行全弓置换＋支架象鼻术的体外循环及双侧脑保护经验.方法 350例DeBakeyⅠ型主动脉夹层患者,当鼻温降至20℃,肛温〈23℃时暂停下半身体外循环,经头臂动脉、左颈总动脉插入Y形双侧脑灌注管行脑灌注.然后完成支架象鼻、弓部置换术.恢复下半身体外循环,缓慢复温,复温至鼻咽温32℃以上,心脏复跳,辅助循环至停机.结果 体外循环时间（156.24±42.25）min;心肌阻断时间（90.82±17.73）min;脑灌注时间（35.78±10.49）min,停循环时间（19.22±9.56）min;死亡11例,死亡率3.13%.结论 DeBakeyⅠ型主动脉夹层在深低温停循环手术,行双侧顺性脑灌注,能提供满意的脑保护效果,安全、可靠、有效,术后并发症少.     

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.     

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.     

Comparative study of brain protection in ascending aorta replacement for acute type A aortic dissection: retrograde cerebral perfusion versus selective antegrade cerebral perfusion

Objectives

Postoperative disorders of the central nervous system remain a major problem in thoracic aortic surgery. Both retrograde cerebral perfusion and selective antegrade cerebral perfusion have become established techniques for cerebral circulatory management. In this study, we compared neurologic outcomes and mortality between retrograde cerebral perfusion and antegrade selective cerebral perfusion in patients with acute type A aortic dissection who underwent emergency ascending aorta replacement.

Methods

Between January 2003 and April 2011, a total of 203 patients with acute type A aortic dissection underwent emergency ascending aorta replacement in our hospital. We performed retrograde cerebral perfusion in 109 patients before 2006, and then mainly performed antegrade selective cerebral perfusion in 94 patients from 2006 onward.

Results

Cardiopulmonary bypass time and systemic circulatory arrest time were significantly longer in the antegrade selective cerebral perfusion group (p?=?0.04, p?<?0.001, respectively). The incidences of transient brain dysfunction and permanent brain dysfunction after surgery did not differ significantly between the groups. There were also no differences between the groups in other intraoperative variables, such as aortic cross-clamp time and the lowest rectal temperature, or in operative outcomes, including postoperative intensive-care-unit stay, mean peak amylase, and lipase levels until postoperative day 7, and 30-day mortality.

Conclusion

Both retrograde cerebral perfusion and antegrade selective cerebral perfusion were associated with acceptable levels of postoperative neurologic deficits, mortality, and morbidity. Either of these techniques for brain protection can be used selectively, based on a comprehensive assessment of general condition, in patients undergoing surgery for acute type A aortic dissection.     

Cannulation of the innominate artery during surgery of the thoracic aorta: our experience in 55 patients.

BACKGROUND: Alternative cannulation sites such as the right/left axillary artery, the ascending aorta and aortic arch have been recently preferred to the femoral artery to improve neurologic outcome in patients undergoing surgery of the thoracic aorta. In 2004, we started to select the innominate artery as an arterial cannulation site for CPB and antegrade cerebral perfusion institution. Here we present our preliminary experience with 55 patients. METHODS: Between November 2004 and 2006, 55 patients (mean age 60+/-14 years) underwent surgery on the thoracic aorta using the innominate artery as a site for arterial cannulation. Indication for surgery was a degenerative aneurysm in 49 (89.1%), an acute type A dissection in 2 patients (3.6%), a post-dissection aneurysm in 3 (5.4%), a supravalvular aortic stenosis in 1 patient (1.8%). Operative procedure included total arch replacement (n=9), hemiarch replacement (n=6), ascending aorta replacement (n=21), Bentall procedure (n=18) and aortoplasty with patch (n=1). Mean CPB and cross clamp times were 131+/-60 and 95+/-29 min, respectively. Mean cerebral perfusion time was 54+/-26 min. RESULTS: The hospital mortality rate was 3.6%. There were no permanent neurologic dysfunction and one (1.8%) temporary neurological dysfunction. CONCLUSION: Our results with the cannulation of the innominate artery were encouraging. This provides the same advantages of the axillary artery cannulation with greater simplicity and avoiding extra surgical incisions which may be site for local complications. It may represent a valid option for CPB and antegrade cerebral perfusion institution in aortic procedures.     

Stanford A型主动脉夹层的外科治疗

目的总结A型主动脉夹层的外科治疗经验。方法回顾分析手术治疗68例StanfordA型主动脉夹层患者的临床资料。其中急性主动脉夹层45例,慢性主动脉夹层23例。采用中低温体外循环53例,深低温停循环(DHCA)和上腔静脉逆行灌注脑保护11例,DHCA加选择性脑灌注4例。急诊手术39例(其中紧急手术19例),择期手术29例。术式为升主动脉置换术7例,升主动脉加右半弓置换术6例,升主动脉加全弓置换术3例,升主动脉加全弓置换加术中支架置入术4例,Bentall手术34例,改良的Wheat术12例,同时行主动脉瓣成形术2例、二尖瓣成形1例。结果全组死亡5例(7%),其中急诊手术3例,急诊手术病死率8%(3/39);择期手术2例,择期手术病死率7%(2/29)。共随访58例,随访率92%(58/63),随访时间(37±22)个月(5~77个月),死亡4例,累积1,3和5年的生存率分别是100%,95%和86%。结论StanfordA型夹层的手术方式应根据内膜破口位置决定,正确的手术指征、技巧和脑保护是手术成功的关键。     

The incidence of transient neurologic dysfunction after ascending aortic replacement with circulatory arrest

BACKGROUND: Transient neurologic dysfunction (TND) namely postoperative confusion, delirium, and agitation after aortic operation, particularly after deep hypothermic circulatory arrest (DHCA), remains an underestimated adverse event in the early outcome of these patients. Although no influence on long-term outcome has been reported so far, this entity markedly affects the early outcome and leads to prolonged intensive care unit and hospital stay. METHODS: Between January 1997 and January 2003, 160 consecutive patients (130 type A dissections [81%] and 30 elective atherosclerotic aneurysms [19%]) had surgical repair with DHCA for a thoracic aortic aneurysm limited to the ascending aorta. From those, 40 patients (25%) underwent DHCA alone, whereas in 13 patients (8%) antegrade cerebral perfusion and in 103 patients (64%) retrograde cerebral perfusion was used for further brain protection. RESULTS: The overall incidence of TND was 18% (28 of 160) with a significant association between duration of circulatory arrest and the incidence of TND (13.8% in DHCA < 30 minutes versus 37.9% in DHCA > 40 minutes; p < 0.05). Furthermore the severity of TND was directly associated with the duration of circulatory arrest and age. In contrast, however, the use of retrograde cerebral perfusion had no influence on the incidence of TND, (p < 0.05). Intensive care unit stay as well as hospital stay were prolonged in the patients with TND (intensive care unit 14.3 +/- 14.2 days versus 10.8 +/- 13.7 days, p < 0.05; hospital stay 15.6 +/- 10.1 days versus 11.4 +/- 7.9 days, p < 0.05). CONCLUSIONS: Duration of DHCA, regardless of whether retrograde cerebral perfusion was used, was the most important predictor of the incidence of transient neurologic dysfunction in patients who had replacement of the ascending thoracic aorta. The occurrence of TND leads to impaired functional recovery as well as prolonged intensive care unit and hospital stay.