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Ann Thorac Surg 1999;67:1883-1886
© 1999 The Society of Thoracic Surgeons

Risk analysis for aortic surgery using hypothermic circulatory arrest with retrograde cerebral perfusion

^a Section of Cardiac Surgery, Department of Surgery, University of Michigan Health Systems, Ann Arbor, Michigan, USA
^b Department of Radiology, University of Michigan Health Systems, Ann Arbor, Michigan, USA
^c Section of Cardiology, Department of Internal Medicine, University of Michigan Health Systems, Ann Arbor, Michigan, USA

Address reprint requests to Dr Deeb, Section of Cardiac Surgery, University of Michigan Health Systems, 1500 E. Medical Center Dr, Ann Arbor, MI 48109-0348
e-mail: mdeeb{at}umich.edu

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

	Abstract

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Background. Retrospective analysis of 144 patients undergoing aortic arch reconstruction using hypothermic circulatory arrest (HCA) with retrograde cerebral perfusion (RCP) for cerebral protection was performed.

Methods. The diagnosis, procedure, and anatomic site of the arch anastomosis were analyzed to see if they were independent predictors of mortality or morbidity. In addition age, gender, HCA-RCP times, preoperative malperfusion (both treated and untreated), surgical status, and redo surgery status were also examined to determine their influence on the incidence of death and complications. Both multivariate and univariate analysis were performed using linear regression and cross-tabulation with either ² or Fisher’s exact test where appropriate.

Results. Preoperative surgical status (emergent) and the presence of untreated preoperative malperfusion were the only variables that were significant independent predictors for mortality (p <0.05). No variable was significant for the prediction of stroke or other complications. The severity of surgery had no bearing on the patient outcome.

Conclusions. Complex aortic surgery using HCA-RCP can be performed with acceptable risk to the patients.

	Introduction

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Hypothermic circulatory arrest (HCA) has been proposed as a technique to protect the central nervous system (CNS) during complex aortic reconstructive surgery (CARS) [1]. Retrograde cerebral perfusion (RCP) has been used as a adjunct to HCA for CNS protection during this type of surgery. The exact mechanism of RCP during HCA is still debatable, but most surgeons agree that it augments maintenance of uniform cerebral cooling during HCA and helps prevent embolization during arrest as well as during initial reperfusion [2–6]. A retrospective analysis was performed on all patients undergoing CARS by one surgeon using HCA with RCP for cerebral protection to determine the risk factors for mortality and morbidity, most specifically stroke.

	Material and methods

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The data were reviewed for 144 patients who underwent CARS with HCA and RCP from May 1993 through December 1997. One hundred and twenty-seven patients were approached through a median sternotomy, while 17 patients underwent surgery through a posterolateral thoracotomy. Univariate analysis was performed to determine if the diagnosis, procedure, or anastomotic site of arch reconstruction was predictive of the mortality or morbidity of surgery (Table 1). For the median sternotomy group, the diagnosis was categorized as either aortic aneurysm or thoracic aortic dissection. The procedure consisted of either root replacement or ascending aorta replacement in association with arch surgery, which was determined by the anatomic site of the distal anastomosis. The anastomotic site was categorized as either open with the anastomosis at the level of the innominate artery, hemi-arch (hemi) with partial arch replacement, or complete arch replacement (Table 2). For the posterolateral group (Table 2), the diagnosis was either degenerative or atherosclerotic (athero), and the procedure was descending thoracic (DT) or thoracoabdominal (TAA).

	Results

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For the median sternotomy approach there were 79 men and 48 women. The mean age was 57 years, with a range of 27–83 years. Forty-five patients were operated upon electively, while 12 were urgent and 70 emergent. Seventy-six patients had a diagnosis of dissection, while 51 had aneurysms. Fifty-six patients had ascending aortic replacement with a distal anastomosis as shown in Table 1: "open," Fig 1A, in 24; hemiarch, Fig 1B, in 17 and complete, Fig 1C, in 15. Seventy-one patients underwent aortic root replacement: the distal anastomosis was "open," Fig 1A, in 14, hemiarch in 44, and complete in 13. Mean HCA-RCP was 50 minutes, with a range of 21–133 minutes (Table 1) (Fig 1).

View larger version (37K): [in this window] [in a new window]   Fig 1. Drawing showing open anastomoses (A), partial arch (B), and complete arch (C) for median sternotomy approach.

Eight patients (6%) suffered a stroke: 6 patients with a diagnosis of dissection (2 with ascending aorta- "open," 2 with aortic root-"open" and 2 with aortic root-complete arch repairs); and 2 patients with aneurysms (1 with ascending-hemiarch, and 1 with ascending-complete arch repair). HCA-RCP time for patients undergoing stroke was a mean of 51 minutes, while the mean time for patients without stroke was 49 minutes.

For mortality, logistic regression showed that diagnosis, procedure, and anastomotic site were not predictive of in-house or 30-day mortality. Univariate analysis showed that surgical status (ie, emergent surgery; p = 0.034) and preoperative untreated malperfusion (p = 0.0012) were the only independent factors that were predictive of mortality. Univariate analysis showed no variable predictive of morbidity (including stroke) in this study population.

For the 17 patients undergoing posterolateral thoracotomy, there were 10 men and 7 women. The mean age was 65 years, and the mean HCA-RCP time was 47 min. There were 4 deaths (24%) and 2 strokes (12%) (Table 2) (Fig 2). The actual number of patients in this group was too small to obtain any significance in the prediction of mortality and morbidity.

View larger version (28K): [in this window] [in a new window]   Fig 2. Drawing showing open anastomoses (A), partial arch (B), and complete arch (C) for posterolateral approach.

	Conclusion

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	References

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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): G. Michael Deeb Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Deeb, G. M. Articles by Shea, M. J. Search for Related Content PubMed PubMed Citation Articles by Deeb, G. M. Articles by Shea, M. J.