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Ann Thorac Surg 1995;60:1294-1298
© 1995 The Society of Thoracic Surgeons

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Original Articles: Cardiovascular

Retrograde Cerebral Perfusion: Anatomic Study of the Distribution of Blood to the Brain

Service de Chirurgie Cardio-Vasculaire et Thoracique, and Laboratoire d'Anatomie, Faculté de Médecine, Angers, France

Accepted for publication June 10, 1995.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Background. Despite apparently good clinical results with retrograde cerebral perfusion during operation on the aortic arch, there is still concern about the real distribution of the blood injected in the superior vena cava to the brain, especially when the internal jugular vein is valvulated (88% of the cases). This anatomic study was carried out to determine how a liquid injected in the superior vena cava reaches the brain.

Methods. Three groups of adult cadavers (5, 5, and 3 cases, respectively) were injected with latex, colored blue, through a cannula in the superior vena cava. In group I, 600 mL of latex was injected. Group II was identical except that a catheter had been inserted, before the injection, into the internal jugular vein to collapse the internal jugular vein valve, when existing. In group III, the azygos vein was ligated.

Results. The internal jugular vein was not valvulated in 2 cases in group I. In those 2 cases, latex was found up to the jugular foramen. In the other cases in group I, and in all cases in group II, where the internal jugular vein was valvulated, the following veins were injected: internal jugular vein up to the valve (almost no latex beyond), azygos vein, inferior vena cava, renal veins, rachidian and perimedullar venous plexuses, and venous sinuses of the brain. In group III, no opacification was observed beyond ligated azygos vein or valvulated internal jugular vein.

Conclusions. Despite the fact that this study was carried out on cadavers, one can assume that, during retrograde cerebral perfusion, the azygos vein system is a major way to the central nervous system when the internal jugular vein is valvulated.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
See also page 1298.

Retrograde cerebral perfusion, as a method of cerebral protection during operation on the aortic arch, is gaining acceptance, even for long durations of cerebral perfusion [1–4]. As the number of reported clinical cases is growing, neurologic damage after operation on the aortic arch seems to be reduced. However, it has not yet been anatomically proved that the blood injected into the superior vena cava (SVC) reaches the brain in the presence of valvulated internal jugular veins (IJVs). The experiments carried out in dogs often use direct injection through the internal maxillary veins [5, 6]. In humans, only metabolic evidence of the real perfusion of the brain has been demonstrated [7]. Anatomic pathways from the SVC to the brain have only been assumed [8], especially in the presence of a valvulated IJV. We present here an anatomic study that shows evidence of the pathways of blood from SVC to the brain.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
This study was carried out in 13 human adult, recently deceased cadavers. A median sternotomy and a bilateral cervicotomy were performed. Superior and inferior venae cavae were controlled, as well as both internal jugular veins and carotid arteries. A 28F cannula was inserted in the SVC through a pursestring suture in the right atrial appendage. Latex Neopren (Safic-Alcan Laboratories, Puteaux, France) was injected through this cannula by means of a pressure cuff set at 70 mm Hg. Pressure monitoring was not performed directly in the SVC. Superior vena caval tapes were applied to prevent backward injection to the right atrium (Fig 1).

View larger version (2K): [in this window] [in a new window]   Fig 1. . Cannula (C) and mediastinal veins. (Arrow = right internal thoracic vein [reclined]; lbv = left brachiocephalic vein; rijv = right internal jugular vein; svc = superior vena cava.)

View larger version (24K): [in this window] [in a new window]   Fig 2. . Anatomic study. (Asterisk = catheter in internal jugular vein [IJV]; Az. V. = azygos vein; black arrow = azygos vein ligated; RA = right atrium; white arrow = inferior vena cava ligated.)

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Valvulated IJVs were found in 11 of the 13 cases (84.6%). In the 2 cases of group I where the IJV was not valvulated, latex was found in the IJV up to the jugular foramen. In all other cases, IJV valves were competent on the right and left sides, and almost no latex was found beyond them (Fig 3), even in group II with the catheter introduced in the IJV.

View larger version (2K): [in this window] [in a new window]   Fig 3. . Opacification of the right internal jugular vein. (ca = right carotid artery; 1 = internal jugular vein below the valve; 2 = internal jugular vein beyond the valve.)

View larger version (2K): [in this window] [in a new window]   Fig 4. . Azygos and intercostal veins (az).

View larger version (2K): [in this window] [in a new window]   Fig 5. . Inferior vena cava (ivc) and left renal vein (arrow). The right kidney has been removed.

View larger version (2K): [in this window] [in a new window]   Fig 6. . Thoracic vertebra: intrarachidian (large arrows) and extrarachidian venous plexuses (small arrows). (S = spinal cord.)

View larger version (2K): [in this window] [in a new window]   Fig 7. . Cervical spinal cord, posterior aspect. (Arrow = posterior vein of the spinal cord.)

View larger version (2K): [in this window] [in a new window]   Fig 8. . Cervical spinal cord, anterior aspect. (Arrow = anterior vein of the spinal cord.)

View larger version (2K): [in this window] [in a new window]   Fig 9. . Venous sinuses of the brain. (Curved arrow = longitudinal sinus; straight arrow = transverse sinus [left].)

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
This anatomic study showed that, even in the presence of valves in the IJV, a liquid injected in the SVC reaches the central nervous system. It also showed evidence for the major role of the azygos vein system between the SVC and the central nervous system, because when the azygos vein is ligated, no latex is found beyond the valves or the ligated vessels. Previous anatomic studies have shown that the IJV is valvulated in a majority of cases: 7 of 7 cases in the study by Dresser and McKinney [9], and 88% of the cases in the study by Midy and associates [10]. The valve is competent in most cases: 6 of 7 cases in the study by Dresser and McKinney [9] and 88% of the cases on the right side and 44% on the left side in the study by Murase and associates [8].

In the present study, all the valves seemed to be competent, although a very small amount of latex was found beyond the valve in the IJV; it was not possible to state if it came through the valve from the SVC, or from a back-flow of the venous sinuses of the brain.

However, in clinical use, it is possible that the IJV valves do not close completely and may flutter, allowing blood to go through the valves and directly perfuse the brain. There is Doppler evidence that this may occur [11], but one cannot rely on this possibility to perfuse the brain directly in 100% of the cases.

In the present study, massive injection of the inferior vena cava and renal veins (and also the injection of the right atrium when the inferior vena cava is not ligated) is consistent with clinical and metabolic observations that only 1% to 20% of the blood injected in the SVC returns through the innominate and left carotid arteries; the rest is drained through the inferior vena cava [12, 13].

From an anatomic point of view, the azygos vein system represents the major anastomosis between the SVC and the inferior vena cava. Furthermore, the vertebral venous system is largely anastomosed with the caval azygo-lumbar systems, and the veins of various viscera (kidney), as shown by Couinaud [14]. The vertebral venous system contributes to the composition of the venous plexus of the foramen magnum, which is largely anastomosed with the intracranial sinuses.

From a physiologic point of view, Batson [15] showed that the vertebral venous system is avalvulated and that the venous pressure remains lower in the vertebral than in the caval venous system when there is a pressure increase in the caval venous system. He stated that ``the direction of flow in these vessels [the vertebral veins] is largely a matter of chance.'' Numerous anatomic studies reported by Couinaud [14] and Batson [15] have shown the importance of the vertebral venous system in the venous drainage of the brain in the presence of a mechanical or functional obstacle in the SVC. Gonzales-Fajardo and associates [16] recently showed, in an experimental model in dogs, a sharp increase in central venous pressure and in intracranial pressure when the SVC and the azygos vein were clamped. This pressure increase was significantly lower when the azygos vein was left unclamped.

The optimal retrograde cerebral perfusion conditions remain to be determined in humans, but it seems reasonable to follow the recommendations given by Usui and associates [5], keeping in mind that the recommended pressure of 25 mm Hg can be obtained with either a low flow through the SVC when the IJV is avalvulated or a higher flow when the IJV is valvulated. Nevertheless, one can assume that, even when the IJV is avalvulated, a great amount of the blood injected in the SVC is drained by the azygos vein and perfuses abdominal organs. Some authors have used total body retrograde perfusion [11, 17] with good clinical results, and state that this technique allows perfusion of abdominal organs (eg, kidneys, liver).

One of the drawbacks of this study is that it is a postmortem experiment, performed with latex; the rate of injection and the pressure monitoring do not reflect exactly the observations made in vivo with blood. Therefore, the results cannot be entirely extrapolated to the clinical use of retrograde cerebral perfusion. However, we showed anatomic evidence for the real perfusion of the brain during retrograde cerebral perfusion through the SVC, even in the presence of a valvulated IJV. Furthermore, the large distribution of the blood injected retrogradely in the SVC might extend the duration of safe circulatory arrest, with better protection, not only of the brain (even and durable cooling, prevention of air and particulate emboli, even in the absence of active metabolism at low temperatures) but also of other organs, such as spinal cord, kidneys, and other abdominal organs.

	Acknowledgments

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
We acknowledge the technical assistance of Mr Stéphane Sourice and Mr Bernard Vivien.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Address reprint requests to Dr de Brux, Service de Chirurgie Cardiovasculaire et Thoracique, CHU d'Angers, 4 rue Larrey 49033, Angers Cedex, France.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 

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