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Ann Thorac Surg 1999;67:1879-1882
© 1999 The Society of Thoracic Surgeons

Retrograde cerebral perfusion for aortic arch surgery: analysis of risk factors

^a Department of Cardiovascular Surgery, Tenri Hospital, Nara, Japan
^b National Cardiovascular Center, Osaka, Japan
^c The Heart Institute of Japan, Tokyo Women’s Medical College, Tokyo, Japan
^d Department of Cardiothoracic Surgery, the University of Tokyo, School of Medicine, Tokyo, Japan

Address reprint requests to Dr Ueda, Department of Cardiovascular Surgery, Tenri Hospital, 200 Mishima, Tenri, Nara 632-8552, Japan;
e-mail: yueda{at}osk.3web.ne.jp

Presented at the Aortic Surgery Symposium VI, April 30–May 1, 1998, New York, NY.

	Abstract

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Background. Retrograde cerebral perfusion (RCP) has been widely adopted during aortic arch surgery under hypothermic circulatory arrest (HCA). However, the risks in terms of mortality and morbidity in aortic arch surgery using HCA with RCP have not yet been confirmed.

Methods. The present study is a retrospective review of 249 patients who underwent aortic arch surgery at three Japanese cardiovascular centers where RCP is a routine adjunct. The median age was 65 years, and 38 patients were more than 75 years old. The pathology in the aortic arch was atherosclerotic aneurysm in 133 patients and dissection in 116. Seventy patients had surgery on an emergency basis. Surgery was performed through a median sternotomy in 182 patients and through a left thoracotomy in 67. Using HCA with RCP, graft replacement of the total aortic arch was performed in 109, the distal arch in 63, and the ascending aorta and hemi-arch in 66; 11 patients had patch repair.

Results. The overall hospital mortality was 25/249 (10%), and 12/70 (17%) in emergent surgery. Stroke developed in 11 patients (4%). The median duration of RCP was 46 minutes (range, 5 to 95). Univariate analysis of risk factors revealed that an age of 75 years or more (p < 0.001), and urgency of surgery (p = 0.02) affected hospital mortality. Multivariate logistic analysis revealed that pump time (p = 0.0001), age (p = 0.0001) and RCP time (p = 0.05) are the most significant risk factors for mortality. The risk factors for mortality and neurological morbidity combined are pump time (p = 0.0001), age (p = 0.0002), and urgency of surgery (p = 0.07); RCP time is marginally significant (p = 0.15).

Conclusions. The dominant risk factors for mortality and morbidity are pump time, urgency of the surgery, and age. RCP is a simple and useful adjunct for aortic arch surgery with up to 80 minutes of HCA, although prolonged RCP is a risk factor for mortality and morbidity.

	Introduction

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Retrograde cerebral perfusion (RCP) has been widely adopted during hypothermic circulatory arrest (HCA) for aortic arch surgery since 1990, when our report of the efficacy of cerebral protection with RCP was published [1]. There has since been sustained support for the use of RCP as an adjunct to HCA for surgery of the aortic arch [2–11]. The quantitative risk of mortality and morbidity in aortic arch surgery using HCA with RCP has not yet been confirmed, although it has been investigated in several reports [9, 12, 13]. A previous survey of 49 institutions in Japan [14] performing aortic arch surgery on 228 patients showed a 20.2% neurological complication rate and a 19.7% in-hospital death rate. These data were collected during the introduction of this technique in Japan and a majority of the hospitals involved had a low volume of surgery. In the present study, the subjects were collected from three Japanese hospitals which had a large volume of surgery, and in which RCP was adopted as a routine adjunct during aortic arch surgery, leading to a more accurate evaluation of the risks and beneficial effects of RCP.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
The subjects were 249 patients who underwent aortic arch surgery at 3 Japanese cardiovascular centers: Tenri Hospital, National Cardiovascular Center, and Tokyo Women’s Medical College, between January 1994 and December 1996. The median age was 65 years (range, 22 to 88) and 38 patients were over 75. The pathology of the aortic arch was atherosclerotic aneurysm in 133 patients and dissection in the remaining 116 patients. Seventy patients underwent surgery on an emergency basis because of rupture of an aneurysm or acute dissection.

Methods
Surgery was performed through a median sternotomy in 182 patients and through a left thoracotomy in 67. The technique of RCP through a median sternotomy has been described by Ueda and associates [1], and the method of RCP via a left lateral thoracotomy by Takamoto and colleagues [11]. Graft replacement of the total aortic arch was performed in 109 patients, of the distal arch in 63, and of the ascending aorta and hemi-arch in 66; 11 patients underwent patch repair.

Univariate statistical analysis employed ² and Student’s t tests. Multivariate stepwise logistic analysis was used to identify independent predictors for mortality and neurological morbidity. Hospital, age, gender, duration of extracorporeal circulation, RCP time, etiology of the aneurysm, urgency of the operation, surgical approach, and extent of the aorta replaced were examined to assess their effect on postoperative mortality and neurological morbidity. Neurological morbidity was defined as coma, stroke, delirium, or obtundation. Statistical analysis was performed with the SAS system (SAS Institute, Inc, Cary, NC, USA).

	Results

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
The overall hospital mortality within 30 days after the operation was 25/249 (10%). The 30-day mortality for elective surgery was 13/179 (7%) and it was 12/70 (17%) for emergency surgery. A stroke was suffered by 11 patients (4%), transient dysfunction including obtundation by 3, delirium such as ICU syndrome by 35 (14%). The median duration of RCP was 46 minutes (range, 5 to 95) and of extracorporeal circulation 174 minutes (range, 87 to 1003). Univariate analysis of risk factors revealed that an age of 75 years or more (p < 0.001) and urgency of the operation (p = 0.02) affected hospital mortality. RCP duration greater than 60 minutes but less than 95 minutes was not a significant risk factor for hospital mortality or neurological morbidity.

Multivariate stepwise logistic analysis revealed that the duration of extracorporeal circulation (p = 0.0001), age (p = 0.0001), and RCP time (p = 0.05) were three significant risk factors for mortality. The relationship between mortality and the duration of extracorporeal circulation, age, and RCP time are shown in Fig 1. The estimated logistic curve shows that mortality rises with increasing RCP time, and suggests that a 50% mortality may be expected when the RCP time reaches 118 minutes.

View larger version (29K): [in this window] [in a new window]   Fig 1. (A) Relationship of mortality and duration of extracorporeal circulation; (B) age of the patient; and (C) RCP time are shown with the estimated logistic curve.

	Comment

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
In recent years, the results of surgery for aortic arch aneurysm and aortic dissection using HCA have generally been favorable. However, much longer times are occasionally required for the reconstruction of the aortic arch and its branches than are generally considered acceptable; in these cases, adjuncts to extend the safe limit of HCA are desirable. RCP entered routine use as an adjunct for prolonged HCA in the 1990s. A previous Japanese survey of 228 patients from 49 institutions, by Usui and associates [14] (in which the mean number of patients per institution was only 4.5 over the 3-year period), showed a 20.2% neurological complication rate, as well as a 19.7% in-hospital death rate. Usui and associates demonstrated that the duration of HCA with RCP was the sole factor predictive of a cerebral complication. These data seemed to imply that widespread and rapid adoption of this technique in both high and low volume centers was associated with no better outcome than HCA alone in experienced institutions [13].

Coselli [4], however, found that the results of aortic arch surgery using HCA with RCP in 290 patients were better than using HCA without RCP in 189 patients. Hospital mortality was significantly improved with RCP: 3.4%, compared to 6.3% without RCP. The RCP time ranged from 10 to 79 min (mean 30.3). Although this duration of HCA may be tolerable without RCP in the majority of patients, outcomes were significantly improved by combining HCA with RCP. Coselli demonstrated, using multivariate logistic analysis, that the variables associated with early mortality in patients with RCP were atherosclerotic heart disease, concurrent coronary artery bypass, aortic cross-clamp time, pump time, and sepsis. Safi and associates [9] also demonstrated that the overall 30-day mortality rate was 6% and the incidence of stroke was 4% in 161 patients who underwent surgery for aneurysms of the descending aorta and transverse arch using HCA and RCP. The use of RCP demonstrated a protective effect against stroke (3/120 patients, 3%) compared with absence of RCP (4/41 patients, 9%; p < 0.05). This benefit was most significant in patients over 70 years of age. Pump time was the sole factor found to be associated with an increased risk of stroke and mortality.

From the present data, univariate analysis demonstrated that an age of more than 75 years and surgery on an emergency basis were the factors associated with death. There was no significant difference in the incidence of stroke and death when patients with RCP times less than and greater than 60 minutes were compared. Okita and associates [7] from the National Cardiovascular Center of Japan reported similar results and concluded that prolonged HCA and RCP (longer than 60 minutes) was not a risk factor for mortality or stroke in patients undergoing aortic arch surgery. Their logistic regression analysis demonstrated that the risk factors for mortality were ruptured aneurysm, chronic obstructive pulmonary disease, arterial cannulation in the ascending aorta, and stroke. However, in these 249 patients from 3 institutions, the stepwise logistic analysis revealed that pump time and age were significant predictors of mortality and morbidity, while the RCP time was of marginal significance (p = 0.052) in determining mortality. Ergin [15] asserted that surgeons should concentrate on limiting HCA time rather than relying on prolonged RCP to extend it because of the increasing potential for harm with RCP as its duration increases. He also stated that limiting HCA time to less than 50 minutes is a readily achievable goal in virtually every case if the operation is planned well.

The mechanism by which RCP provides brain protection is not yet fully clear. Advantages of RCP include uniform brain cooling, easy de-airing of the arch vessels, the capability of limiting cerebral embolism, flushing of toxic metabolites that accumulate during HCA, and provision of oxygen and substrates. Clearly, persistent filling of the arterial circulation with effluent blood during periods of HCA reduces the risk of embolism of air and material debris [12]. Prevention of perioperative embolic stroke in elderly patients has been a daunting problem, and we believe that RCP may prove to be more useful in solving this problem than in shortening the interval of HCA.

In conclusion, the present study has confirmed that RCP is a simple and useful adjunct for aortic arch surgery for up to 80 minutes of HCA, although prolonged RCP may be a risk factor for mortality and morbidity. The dominant risk factors for mortality and morbidity are pump time, urgency of surgery, and age of the patient.

	Acknowledgments

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
This work was supported by a Research Grant for Cardiovascular Disease (6C-3) from the Ministry of Health and Welfare, Japan. We acknowledge the assistance of Shunzo Meatani, MD, PhD, Tenri Institute of Medical Research, for his statistical contributions to this manuscript.

	References

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 

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4. Coselli J.S. Retrograde cerebral perfusion: Is it valuable adjunct during circulatory arrest?. In: Kawashima Y., Takamoto S., eds. Brain protection in Aortic Surgery. Amsterdam: Elsevier, 1997:167-181.
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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Yuichi Ueda Yutaka Okita Shigeyuki Aomi Hitoshi Koyanagi Shinichi Takamoto Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Ueda, Y. Articles by Takamoto, S. Search for Related Content PubMed PubMed Citation Articles by Ueda, Y. Articles by Takamoto, S.