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Ann Thorac Surg 1999;67:1904-1910
© 1999 The Society of Thoracic Surgeons
a Department of Cardiothoracic Surgery, St. Antonius Ziekenhuis, Nieuwegein, the Netherlands
b Department of Anesthesiology, St. Antonius Ziekenhuis, Nieuwegein, the Netherlands
Address correspondence to Dr Dossche, Department of Cardiothoracic Surgery, St. Antonius Ziekenhuis, Koekoekslaan 1, 3435 CM Nieuwegein, the Netherlands
Presented at the Aortic Surgery Symposium VI, April 30–May 1, 1998, New York, NY.
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Abstract |
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 Top Abstract IntroductionPatients and methodsResultsCommentReferences |
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Methods. From May 1989 through April 1997, 106 patients underwent surgery on the thoracic aorta using circulatory arrest and antegrade selective cerebral perfusion. Mean age was 64.0 ± 11.5 years. Unilateral antegrade cerebral perfusion was used in 37 patients (35%), bihemispheric antegrade cerebral perfusion in 69 patients (65%). Mean antegrade cerebral perfusion time was 50.5 ± 20.5 minutes. Indication for surgery was atherosclerotic aneurysm in 60 (56.5%) patients, postdissection aneurysm in 26 (24.4%), acute type A dissection in 16 (15.1%), other in 4 (4.0%).
Results. Hospital mortality was 8.5% (n = 9; 70% CL: 5.8%–11.2%). Independent predictors of hospital mortality were rethoracotomy (odds ratio 5.7, p = 0.02), postoperative temporary (odds ratio 17.3, p = 0.02) or permanent (odds ratio 7.5, p = 0.03) neurologic dysfunction, postoperative dialysis (odds ratio 9.9, p = 0.008). Bilateral antegrade selective cerebral perfusion had a favorable impact on hospital mortality (odds ratio 0.08, p = 0.007). Temporary neurologic dysfunction occurred in 3.8% of patients (n = 4; 70% CL: 2.0%–5.6%); preoperative hemodynamic instability (odds ratio 14.8, p = 0.05) and perioperative technical problems (odds ratio 22.2, p = 0.033) were independent determinants of temporary neurologic dysfunction. Permanent central neurologic damage occurred in 5.4% of patients (n = 6; 70% CL: 3.2%–7.6%). Preoperative hemodynamic instability (odds ratio 18.9, p = 0.009) and approach through a left thoracotomy (odds ratio 9.4, p = 0.031) were significant predictors of permanent neurologic damage.
Conclusions. Hospital mortality is affected significantly by the choice of technique used for antegrade cerebral perfusion. The incidence of both temporary and permanent postoperative central neurologic damage is influenced by preoperative hemodynamic instability. Duration of cerebral perfusion had no influence on the postoperative neurologic outcome.
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Introduction |
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TopAbstractIntroductionPatients and methodsResultsCommentReferences |
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The purpose of our study was twofold: (1) does ASCP, either unilateral or bilateral, protect the central nervous system during circulatory arrest and (2) what factors influence hospital mortality and neurologic outcome?
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Patients and methods |
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TopAbstractIntroductionPatients and methodsResultsCommentReferences |
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All electively operated patients underwent preoperative examination to detect important carotid disease (defined as any stenosis of > 70% of the common carotid or internal carotid artery) and to assess the patency of the circle of Willis. This included Doppler ultrasound of the extracranial vessels, digital subtraction angiography of the extracranial and intracranial circulation, carotid compression test with monitoring by electroencephalogram to evaluate occlusion intolerance or a transcranial Doppler ultrasound study.
Operative technique
A median sternotomy was used in 97 (91.5%) patients; extension of the incision along the anterior border of the left sternocleidomastoid muscle was only occasionally used. After systemic heparinization, extracorporeal circulation was instituted. In general, the cannula for arterial return was placed in a femoral artery and a single two-stage cannula for venous return in the right atrium. The left side of the heart was vented through the right superior pulmonary vein. Myocardial protection was achieved with cold crystalloid cardioplegia and continuous topical hypothermia in the pericardial well.
In the remaining 9 (8.5%) patients, the diseased aorta was exposed through a left posterolateral thoracotomy. Extracorporeal circulation was instituted with the arterial return cannula in the left femoral artery and a long venous cannula through the left femoral vein into the right atrium. Myocardial protection was achieved with cold crystalloid cadioplegia; a large bore catheter was placed into the apex of the left ventricle for cardiac decompression.
ASCP with 2 time-related modifications was used in all patients to prevent cerebral ischemia. From May 1989 to September 1995, selective brachiocephalic perfusion under simultaneous conditions of deep hypothermic circulatory arrest (blood temperature ± 14°C, nasopharyngeal temperature ± 17°C, isoelectric EEG) was applied in 37 patients [7]. Arterial access was achieved with 2 cannulas joined to a Y connector, which was attached to a single head on the arterial roller pump. Usually a 20F Sarns cannula (Sarns, 3M Health Care, Ann Arbor, MI) was inserted into the femoral artery; a right angled 15F cannula (Medtronic DLP, Grand Rapids, MI) was inserted into the distal innominate artery through a purse-string suture. At moderate hypothermia (26°C to 28°C nasopharyngeal temperature), the left common carotid artery was clamped temporarily to test the competence of the circle of Willis. If major EEG changes were reported within three minutes of left common carotid occlusion, another right angled 13F cannula (Medtronic DLP) was inserted in the left common carotid artery (5 patients). Once deep hypothermia was reached, body perfusion was stopped and brain perfusion was started. In case of innominate artery perfusion, flow rates of 400 mL/min were maintained and the left common carotid and left subclavian artery were clamped; in case of innominate and left common carotid artery perfusion, a flow rate of 800 mL/min was maintained and the left subclavian artery was clamped to avoid a steal phenomenon. Perfusion pressure was monitored by the right radial artery pressure and kept at ± 40 mm Hg. Throughout the period of body circulatory arrest, blood temperature was kept at ± 14°C and nasopharyngeal temperature at ± 17°C. The EEG remained isoelectric throughout the period of ASCP (cold blood perfusion); the head was packed with ice.
From October 1995 to April 1997, bilateral ASCP as described by Kazui and coworkers [9, 10] was used in 69 patients. In short, the technique consisted in the following. Patients were cooled down to nasopharyngeal temperatures of 22°C to 25°C. Systemic circulation was then arrested and the aortic arch was opened in continuity with the rest of the aneurysm. Under visual control and with the patient in Trendelenburg position, the cannulas for antegrade cerebral perfusion were inserted into the innominate and left common carotid artery; for the innominate artery, usually a 15F retrograde coronary sinus perfusion cannula with manual-inflating cuff and silicone body was used (Medtronic DLP), for the left common carotid artery, a 13F (Medtronic DLP) cannula was inserted. In addition, the left subclavian artery was either clamped or occluded with a Fogarty (Baxter Health Care, Irvine, CA) catheter. Blood was then perfused into both arteries at a rate of 10 mL/kg/min using a single roller pump separated from the systemic circulation. The cerebral perfusion pressure was adjusted to maintain a right radial arterial pressure of 40 to 70 mm Hg. During the period of body circulation arrest, nasopharyngeal temperatures and blood temperatures are kept at 25°C; occasionally, the EEG disappeared during cooling of the patient, but was usually restored within a few minutes when the brain became perfused with blood at 25°C. If available, transcranial Doppler measurements of blood velocity of the middle cerebral artery (MCA) confirmed the proper placement and function of both cannulas.
Open distal aortic anastomosis was made in all 106 procedures. While performing the distal aortic anastomosis, blood perfusion to the lower half of the body was arrested.
Table 1 summarizes the operative techniques. Concomitant procedures included planned coronary artery bypass grafting in 19 patients, unforeseen coronary artery bypass grafting due to right ventricular failure in 2 patients, mitral valve replacement or repair in 4 patients, and prosthetic ilio-femoral bypass in 1 patient.
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2 test or Fisher’s exact test) to determine whether any single variable influenced early mortality and postoperative central neurologic complications. The extent of replacement was simplified into 3 major groups according to the segment that dominated the repair. The group of proximal repair included all patients with ascending and aortic root operations and replacement of the proximal portion of the aortic arch. Arch replacement was defined as those procedures involving the total replacement of the aortic arch with or without replacement of the varying portions of the ascending aorta, root, or the aortic valve. The distal arch and descending aorta group included all patients with replacement of varying portions of the descending aorta and the distal hemiarch. A variable with p value of less than 0.05 was found to be significant and then analyzed using multivariate analysis; a multiple logistic regression model was used to determine the independent predictability of the retained variables in influencing early mortality and postoperative central neurologic complications. All computations were performed with the aid of BMDP (BMDP Software, Los Angeles, CA) and the SAS (SAS Institute, Cary, NC) statistical software packages. |
Results |
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TopAbstractIntroductionPatients and methodsResultsCommentReferences |
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Five factors were retained as independent predictors of hospital mortality with significant relative risk factors calculated by logistic regression analysis: rethoracotomy for any cause (odds ratio 5.7, p = 0.02), postoperative temporary (odds ratio 17.3, p = 0.02) or permanent (odds ratio 7.5, p = 0.02) neurologic dysfunction, postoperative need for hemodialysis (odds ratio 9.9, p = 0.008); bilateral ASCP had a favorable influence on hospital mortality (odds ratio 0.08, p = 0.007) (Table 2).
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Transient neurologic dysfunction, defined as postoperative confusion, lethargy, limited ataxia or parkinsonism which were associated with negative computed tomographic scanning and complete resolution of symptoms before discharge [5] occurred in 4 (3.8%; 70% CL: 2.0%–5.6%) patients. On univariate analysis, preoperative hemodynamic instability (p = 0.032), emergency operation (p = 0.019) and technical problems (each problem requiring repeat cross-clamping of the aorta for more than 10 minutes with repeat cardioplegic arrest or reintervention within 24 hours with exclusion of tamponade and excessive bleeding) (p = 0.01) emerged as dominant determinants predicting temporary neurologic dysfunction. By multiple logistic regression, independent predictors of temporary neurologic dysfunction were (1) preoperative hemodynamic instability (odds ratio 14.8, p = 0.005) and (2) perioperative technical problems (odds ratio 22.2, p = 0.033).
Permanent neurologic injury (defined as any lateralizing deficit that was present immediately postoperatively, ie without free interval, but not preoperatively) was reported in 6 (5.4%; 70% CL: 3.2%–7.6%) patients. Four patients suffered an ischemic stroke: 3 of them were patients with acute type A dissection with involvement of the arch vessels, 1 patient had bilateral hemodynamically significant extracranial vascular disease. During initiation of cardiopulmonary bypass a prolonged period of hypotension occurred resulting in cerebral ischemia. Another 2 patients suffered an embolic stroke: 1 due to embolization of air, the other due to embolization of clot or atheroma into the arch vessels. Both patients had multiple cerebral infarctions on postoperative brain computed tomographic scanning; the patient with embolization of clot or atheroma died subsequently, and the other patient recovered completely. Finally, 1 patient had intracerebral bleeding on the 10th postoperative day, but this was not considered a complication related to the operative procedure; he recovered completely.
On univariate analysis, preoperative hemodynamic instability (p = 0.003), emergency operation (p = 0.015) and approach through a left thoracotomy (p = 0.037) showed statistically significant correlation with the occurrence of permanent neurologic dysfunction. On multiple logistic regression analysis preoperative hemodynamic instability (odds ratio 18.9, p = 0.009) and approach through a left thoracotomy (odds ratio 9.4, p = 0.031) were found to be independent predictors of permanent neurologic dysfunction.
Peri-operative technical problems were encountered in 3 (2.8%; 70% CL: 1.2%–4.4%) patients. In 2 patients, a revascularization of the right coronary artery with a venous graft was necessary because of right ventricular failure; in another patient, diffuse bleeding from all anastomotic sites required repeat cardioplegic arrest to inspect the sutures from within the implanted aortic prosthesis.
Postoperative myocardial infarction (serum CPK level > 300 IU/L with a CPK-MB fraction > 3 %) occurred in 4 (3.7%; 70% CL: 1.9%–5.5%) patients. Two of these patients presented with acute type A dissection and did not undergo preoperative coronary angiography. Postoperative coronary angiography revealed 3-vessel disease in 1 of them, requiring a PTCA procedure of the target lesion. Two other patients suffered a right ventricular infarction and needed a venous bypass to the right coronary artery. There was no increased mortality in this subgroup (p = 0.537).
Nine (8.5%; 70% CL: 5.8%–11.2%) patients underwent an early (< 24 hours after initial operation) reintervention for excessive bleeding or cardiac tamponade. In another 9 (8.5%; 70% CL: 5.8%–11.2%) patients with diffuse bleeding from various anastomotic sites, compresses were left in place for 24 hours, after which they were removed. Wound infection and mediastinitis occurred in 2 (1.8%; 70% CL: 0.5%–3.1%) patients; this was treated surgically with extensive debridement of all infected tissue and omentoplasty or a pectoral muscle flap. In 4 patients, a salvage reintervention was performed on the postoperative ward because of acute shock. Three of these patients died of exsanguination due to rupture of a distal aneurysm; 1 patient with a dehiscence of a suture was treated successfully.
Respiratory insufficiency (mechanical ventilation for more than 5 days or need for reintubation due to respiratory failure) occurred in 10 (9.4%; 70% CL: 6.6%–12.2%) patients; 1 of them had medically treated chronic obstructive pulmonary disease. Another 5 (4.7%; 70% CL: 2.6%–6.8%) patients needed a tracheotomy: 3 of these patients died in the hospital; 2 recovered well. Respiratory insufficiency had no negative impact on hospital outcome (p = 0.086).
Stable elevated creatinine levels (> 150 µmol/L) were present in 7 (6.6%; 70% CL: 4.2%–9.0%) patients; 2 already had elevated creatinine levels preoperatively. Temporary hemodialysis was necessary in 6 (5.6%; 70% CL: 3.4%–7.8%) patients: 3 died in the hospital; the other 3 recovered without need for long-term hemodialysis. The need for postoperative hemodialysis was a strong incremental risk factor for hospital mortality (odds 9.9, p = 0.008).
Extracorporeal circulation data
Total pump time ranged from 96 to 715 minutes, mean 239.8 ± 84.4 minutes; aortic cross-clamp time ranged from 32 to 557 minutes, mean 132.9 ± 63.2 minutes and ASCP time ranged from 16 to 114 minutes, mean 50.5 ± 20.3 minutes. In 67 (63.2%) patients, ASCP time exceeded 45 minutes; in 21 (20%) patients, ASCP time was beyond 60 minutes.
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Comment |
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TopAbstractIntroductionPatients and methodsResultsCommentReferences |
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Since 1989, we have been using ASCP as an adjunct to extend the safe period of circulatory arrest in patients undergoing repair of the thoracic aorta in whom a circulatory arrest period of more than 30 minutes is anticipated. Initially, a combination of deep hypothermia and unilateral ASCP through a cannula in the innominate artery, a modification of the Stanford technique [7], was used. We abandoned this technique for several reasons:
In 1995, we adopted the bilateral ASCP technique described by Kazui and associates [9, 10]. In short, major advantages of this technique are as follows:
Some authors have suggested that manipulation of the tributaries of the aortic arch may be hazardous in situations of acute dissection (fragile aorta and dissection up into the brachiocephalic arteries) or in the presence of loose atheroma in the aortic arch (risk of embolization) [14]. Up to date, we have not encountered any problem or complication due to the freeing of the arch vessels. Bachet and associates did not encounter this problem in their series of 54 patients [8]; Kazui and coworkers described no complications associated with manipulation of the arch vessels or introduction of the ASCP cannulas [9, 10].
The careful introduction and proper positioning of the cannulas for ASCP is of extreme importance. Care has to be taken that the whole system is completely de-aired before introduction into the arch vessels. One of our patients suffered multiple cerebral infarctions due to inadequate de-airing of the tubes. It is the only patient in our series with a complication directly related to the use of ASCP. The correct positioning of the ASCP cannulas may be troublesome in situations of acute dissection with involvement of the arch vessels because of difficulties in identifying the true lumen. Three patients with acute type A dissection suffered a postoperative stroke, although EEG recordings and ASCP flow and perfusion pressure monitoring during the operation remained within the normal range. Whether the stroke incidence was caused by incorrect positioning of the ASCP cannulas, or by the poor pre-operative hemodynamic condition of these patients is an open question. Therefore, we found the use of bilateral TCD monitoring during procedures with ASCP very useful. It allows measurement of blood flow through both left and right middle cerebral arteries and provides the surgical team with immediate information on the position of the ASCP cannulas, and of impairment of blood flow through the cannulas due to kinking or malposition. In experienced hands, it takes little time to set up the TCD monitoring system and it does not add additional complexity to the operation. As no single method reflects the functioning of ASCP adequately, we feel that a combination of several techniques (pressure monitoring, EEG, TCD) provides the best assessment.
Postoperative neurologic complications were classified into 2 groups, ie temporary neurologic dysfunction, a symptom complex defined by Ergin and associates [5], and permanent neurologic dysfunction. In the present series with a mean circulatory arrest time (with ASCP) of 50.5 minutes, the incidence of temporary neurologic dysfunction was 3.8%. Pre-operative hemodynamic instability and perioperative technical problems were independent determinants of postoperative temporary neurologic dysfunction. Duration of circulatory arrest was not an incremental risk factor for temporary neurologic dysfunction, in contrast to findings of Ergin and associates [5]. They found in their series (with a mean profound hypothermic circulatory arrest time of 36 minutes), an incidence of temporary neurologic dysfunction of 18%. Advanced age and the duration of circulatory arrest were independent determinants of temporary neurologic dysfunction. No other comparable clinical information is available in the current literature. The findings from our study clearly suggest that temporary neurologic dysfunction is related to factors other than duration of circulatory arrest with ASCP, even with longer periods of circulatory arrest. To some [15], temporary neurologic dysfunction appears to be caused by alterations in microcirculation or by gaseous emboli during prolonged periods of rewarming; to others [5], it is a manifestation of transient neurologic injury. It could well be that, by perfusing the brain with blood at 22°C to 25°C, as is the case with bilateral ASCP, there is less risk of alterations in the microcirculation or production of gaseous emboli. Henriksen and associates [16] have demonstrated that prolonged rewarming increases the risk of microembolism and is associated with cerebral hyperperfusion. By not cooling patients below 22°C to 25°C nasopharyngeal, as we did in all patients with bilateral ASCP, rewarming time is reduced, which may reduce complications associated with the rewarming process. Other studies using ASCP and moderate hypothermia will be necessary to confirm our findings on the temporary neurologic dysfunction.
Permanent neurologic deficits were seen in 5.6% of patients. This compares favorably with recent reports using only profound hypothermic circulatory arrest. Ergin [5] found an overall incidence of permanent neurologic deficit of 9%; embolic strokes with permanent deficits occurred in 6.9% of patients and correlated with increased age and the presence of clot or atheroma in arch or descending aortic aneurysms. Svensson [6] reported an overall incidence of stroke with permanent deficit of 7% in their series of 656 patients. However, beyond 40 minutes of profound hypothermic circulatory arrest, the incidence of stroke was more than 10%. In the present study, we could not find any correlation between duration of circulatory arrest with ASCP and permanent neurologic damage. Approach of the diseased aorta through a left posterolateral thoracotomy proved to be an incremental risk factor for permanent neurologic damage. Therefore, the combination of excessive manipulation and retrograde perfusion of the aorta should be avoided as much as possible in patients with extensive atheromatous disease of the descending aorta and arch in order to prevent embolization of clot or atheroma. Other studies using ASCP report an incidence of stroke between 1.3% and 10.5% [8–11].
The overall mortality rate of 8.5% observed in this group of patients compares favorably with that in other similar series. Kazui and associates reported an overall mortality rate of 16.3% for arch replacement with bilateral ASCP [9, 10]. In their series, preoperative critical dysfunction and reoperation were independent predictors of hospital mortality. Hayashi and colleagues recently reported a hospital mortality of 25.2% in 143 patients operated for nondissecting thoracic aneurysm. They did not include patients with acute type A dissection and did not include multivariate analysis of factors influencing hospital mortality [11]. These figures for ASCP methods can be compared with the operative mortality seen with circulatory arrest. Svensson and associates reported a 30-day mortality of 10% [6]; Ergin and associates [5] reported a hospital mortality of 15%. In the series of Ergin, independent risk factors for hospital mortality were emergency operation and hemodynamic compromise, concomitant procedure and permanent neurologic dysfunction [5]. We found in our series that rethoracotomy, temporary or permanent neurologic dysfunction and postoperative renal dysfunction requiring hemodialysis were incremental risk factors for hospital death. However, the use of bilateral ASCP had a favourable impact on hospital outcome. We were unable to find any significant effect on mortality of any of the perfusion parameters including bypass time, myocardial ischemia time and duration of ASCP.
The use of ASCP during operations on the thoracic aorta does not create additional technique-related difficulties or complications. The incidence of temporary or permanent neurologic dysfunction is not related to the duration of ASCP. It is influenced by the preoperative hemodynamic condition and other perioperative factors. Hospital mortality is strongly influenced by the presence of postoperative neurologic dysfunction; perfusion parameters are of no influence. The use of bilateral ASCP has a favorable impact on hospital outcome. Based on these findings, we will continue to use the technique of bilateral ASCP.
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Appendix |
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ASCP = antegrade selective cerebral perfusion; COPD = chronic obstructive pulmonary disease; EF = ejection fraction.
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