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Ann Thorac Surg 2000;70:10-15
© 2000 The Society of Thoracic Surgeons

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Original articles: Cardiovascular

Antegrade selective cerebral perfusion during operations on the thoracic aorta: our experience

^a Department of Cardiac Surgery, University of Bologna, Bologna, Italy

Address reprint requests to Dr Di Bartolomeo, Department of Cardiac Surgery, University of Bologna, Policlinico Santa Orsola, Via Massarenti 9, 40138 Bologna, Italia
e-mail: apierangeli{at}orsola-malpighi.med.unibo.it

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. Various methods of cerebral protection have been used during aortic arch operations. Deep hypothermia with circulatory arrest is the most common technique but has a limited safe period for circulatory arrest. Selective cerebral perfusion has been introduced to prolong this safe period. We reviewed our experience with antegrade selective cerebral perfusion during surgical repair of the thoracic aorta.

Methods. Between November 1996 and December 1998, 57 consecutive patients were operated on for aortic arch aneurysms using selective cerebral perfusion. Forty-one were men (71.9%), and 16 were women. The mean age was 63.2 years. Thirty-seven patients had chronic aneurysms, and 20 had type A acute dissection. Preoperative, intraoperative, and postoperative factors were analyzed by univariate and multivariate analysis to identify predictors of early mortality and transient neurologic dysfunction.

Results. There were no permanent neurologic deficits. The early mortality rate was 8.8% (5 patients). Multivariate analysis revealed preoperative renal failure (p = 0.0338) and repeat thoracotomy for bleeding (p = 0.0201) to be independent risk factors for early mortality. The factor postoperative cardiac complications (p = 0.0368) was the only independent predictor of transient neurologic dysfunction, and it occurred in 3 patients (5.3%).

Conclusions. The present study confirmed that preoperative renal failure and repeat thoracotomy for bleeding are significant predictors of mortality in aortic arch operations using selective cerebral perfusion and that cerebral perfusion time has no influence on the postoperative outcome. We believe that selective cerebral perfusion is an optimal technique of cerebral protection during operations on the aortic arch.

	Introduction

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Cerebral protection is one of the most important concerns during aortic arch repair, and various methods to accomplish it have been introduced. Deep hypothermia with circulatory arrest (DHCA) is a well-established technique; it provides both good cerebral protection, even though time limited, and a dry operative field [1–5]. However, it requires prolonged cardiopulmonary bypass (CPB) time and is often associated with coagulopathy and pulmonary complications. Retrograde cerebral perfusion has been introduced to improve cerebral protection and to prolong the "safe" time of circulatory arrest, though the mechanisms of the protective effect are not entirely understood [6–9]. Moreover, the complications resulting from deep hypothermia remain largely unchanged with this method.

In 1996, we began using antegrade selective cerebral perfusion (SCP) with moderate hypothermia during aortic arch operations. Here we present our experience with this method in 57 consecutive patients.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
From November 1996 to December 1998, 57 consecutive patients underwent surgical treatment of aortic disease involving the aortic arch. Twenty patients (35.1%) were treated for type A acute dissection, 9 (15.8%) for chronic dissection, and 28 (49.1%) for true aneurysms. There were 41 men (71.9%) and 16 women (28.1%) with a mean age of 63.2 ± 10.1 years (± the standard deviation) (range, 32 to 77 years). Thirty-six patients were operated on electively (63.2%), and 21 (36.8%) had emergency operation (20 for acute dissection and 1 for impending aneurysmal rupture).

Associated diseases included hypertension in 33 patients (57.9%), coronary artery disease in 12 (21.1%), chronic obstructive pulmonary disease in 11 (19.3%), chronic renal dysfunction (defined as a serum creatinine level exceeding 2 mg/dL) in 6 (10.5%), and diabetes in 3 (5.3%). Symptomatic cerebral vascular disease was present in 6 patients (10.5%): 4 had transient ischemic attack and 2, stroke. Twenty patients were smokers (35.1%). Nine patients (15.8%) had undergone previous surgical procedures: ascending aorta replacement in 2 patients, descending aorta replacement in 1, aortic valve replacement in 2, coronary artery bypass grafting in 2, coronary artery bypass grafting and aortic valve replacement in 1, and aortic valve replacement and tailoring aortoplasty of the ascending aorta in 1. Preoperative evaluation of cerebral circulation was performed with Doppler echocardiography, digital angiography, or both in all patients having an elective operation.

Operative techniques
Median sternotomy was used in 52 patients (91.2%) and median sternotomy plus left anterolateral thoracotomy in 5 (8.8%). After systemic heparinization, standard CPB was instituted. The arterial cannula was inserted into the femoral artery, and a single two-stage cannula was placed in the right atrium. The left side of the heart was vented through the right superior pulmonary vein. Myocardial protection was provided with cold crystalloid cardioplegia and topical cooling.

Selective cerebral perfusion as described by Kazui and associates [10] was used in all patients to prevent ischemic brain damage during the aortic surgical procedure. As the patient was cooled to a nasopharyngeal temperature of 22° to 25°C, the systemic circulation was arrested, and the ascending aorta or aortic arch wall was opened. With the patient in the Trendelenburg position, 15F retrograde coronary sinus perfusion cannulas (Chase Medical Inc, Houston, TX) were inserted into the innominate and left common carotid arteries through the aortic lumen. The left subclavian artery was clamped or occluded with a Fogarty catheter (IFM, Clearwater, FL) to prevent a steal phenomenon. With a one-roller pump separated from the systemic circulation, cerebral blood flow was initiated at 10 mL · kg^-1 · min^-1 and adjusted to maintain a right radial pressure between 40 and 70 mm of Hg.

Open distal aortic anastomosis was performed with systemic blood flow maintained at 0.5 to 1 L/min [11]. Graft replacement was used for aortic reconstruction in all patients. With respect to the extent of replacement, ascending aorta and hemiarch replacement was performed in 19 patients (33.3%), ascending aorta and total arch replacement in 27 patients (47.4%), total arch replacement in 5 patients (8.8%), and total arch and descending aorta replacement in 3 patients (5.3%). Complete replacement of the thoracic aorta (ascending aorta, arch, and descending aorta) was performed in 3 patients. In the case of total arch replacement, supraaortic vessels were reimplanted using en bloc [12] or separated graft techniques. Concomitant procedures included aortic valve replacement in 13 patients (22.8%), composite graft implantation (modified Bentall procedure) [13] in 12 patients (21.1%), and coronary artery bypass grafting in 5 patients (8.8%).

Cardiopulmonary bypass data
The mean CPB time was 167.1 ± 42.4 minutes (range, 85 to 360 minutes), and the mean aortic cross-clamp time was 100.9 ± 32.9 minutes (range, 37 to 208 minutes). Complete circulatory arrest time, defined as the time between the suspension of systemic circulation and the beginning of SCP, ranged from 2 to 11 minutes (mean time, 4.2 ± 2.2 minutes). The mean SCP time was 51.6 ± 29.5 minutes (range, 18 to 140 minutes): 18 patients (31.6%) had an SCP time longer than 60 minutes and only 13 (22.8%), a time shorter than 31 minutes (Fig 1).

View larger version (40K): [in this window] [in a new window]   Fig 1. Distribution of patients (pts) by duration of selective cerebral perfusion.

Statistical analysis was performed using SPSS 7.0 statistical software (SPSS Inc, Chicago, IL). Continuous variables were expressed as the mean ± one standard deviation and categorical variables, as percentages. All variables were first analyzed using univariate analysis (unpaired two-tailed t test, ² test, or Fisher’s exact test when appropriate) to determine whether any one factor influenced early mortality and transient neurologic dysfunction. A p value of less than 0.05 was taken to indicate significance. Variables that achieved a p value of less than 0.2 in the univariate analysis were examined using multivariate analysis by forward stepwise logistic regression to evaluate independent risk factors for hospital mortality and transient neurologic dysfunction. Survival data were analyzed with standard Kaplan-Meier actuarial technique for estimation of survival probabilities.

	Results

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Early results
There were no operative deaths and five early deaths (8.8%), defined as death within 30 days after operation. Three of the 5 patients were operated on for acute dissection, 1 for impending aortic aneurysmal rupture, and 1 for chronic aneurysm. Two patients died of multiple-organ failure, 1 of acute myocardial infarction, 1 of septic shock, and 1 of bleeding. On univariate analysis, the following factors had a significant influence on 30-day mortality: preoperative renal failure (p = 0.025), CPB time (p = 0.006), coronary artery bypass grafting (p = 0.010), postoperative renal failure (p = 0.048), and repeat thoracotomy for bleeding (p = 0.003) (Table 1). Multivariate analysis revealed preoperative renal failure (odds ratio, 21.8; p = 0.034) and repeat thoracotomy for bleeding (odds ratio, 35.9; p = 0.020) to be independent predictors of 30-day mortality (Table 2).

Medium-term results
The overall survival curve is depicted in Figure 2. The 20-month survival rate was 82.3% ± 5.5%. During a mean follow-up of 19.1 months (range, 3 to 23.4 months), there were five deaths. Two patients died of multiple-organ failure, 2 of cancer, and 1 of pulmonary insufficiency.

View larger version (17K): [in this window] [in a new window]   Fig 2. Actuarial survival rates after thoracic aorta replacement using selective cerebral perfusion. Early and late deaths are included (+ = censored).

	Comment

Top Abstract Introduction Material and methods Results Comment References

Deep hypothermia with circulatory arrest, first used in 1974 by Pierangeli and associates [1, 2] in the time-consuming operation prosthetic replacement of the aortic arch, is a simple and valid method. This technique has the disadvantage of a limited "safe" time of circulatory arrest (< 40 minutes at 18°C); the incidence of both stroke and mortality increases with a circulatory arrest time longer than 45 minutes and 60 minutes, respectively [3]. With this technique, the incidence of cerebral complications ranges from 7% to 10% [3–5]. In our experience [14], permanent neurologic deficit occurred in 5.4% of patients and transient neurologic dysfunction, in 6.7%. Further, prolonged CPB, necessary to cool and rewarm patients, increases the risk of coagulation deficits, pulmonary complications, and microembolisms [15].

Retrograde cerebral perfusion associated with DHCA was introduced to extend the "safe" period of circulatory arrest, and good results have been reported [6–9]. Coselli and associates [16] did not report any transient or permanent neurologic deficits in 111 patients. However, this technique does not avoid the problems associated with DHCA. We had a very limited experience with retrograde cerebral perfusion, and the results were similar to those obtained with DHCA.

Since November 1996, we have been using SCP as described by Kazui and coworkers [10, 11, 17], and our results have been very encouraging. This technique provides moderate hypothermia (22° to 25°C), which reduces the problems caused by deep hypothermia and prevents ischemic injury to the abdominal viscera and the spinal cord. Cerebral perfusion is obtained by cannulating the innominate and left common carotid arteries and is regulated by a single roller pump separated from the systemic circulation. The blood is perfused at a rate of 10 mg · kg^-1 · min^-1.

Selective cerebral perfusion has considerably prolonged the "safe" time of circulatory arrest, thereby allowing more complex and time-consuming aortic arch reconstructions. Although the mean time of SCP was 51.6 minutes with a duration of longer than 60 minutes in 18 patients (31.6%), we observed no permanent postoperative neurologic deficits. In a series of 100 patients, Kazui and colleagues [17] reported only one postoperative stroke, which occurred in a patient with a duration of cerebral perfusion longer than 90 minutes. In other reports [18–20], the incidence of stroke ranged from 3.7% to 10.5%.

In the present study, transient neurologic dysfunction occurred in just 3 patients (5.3%). The only independent risk factor for temporary neurologic dysfunction was postoperative cardiac complications. However, total circulatory arrest time, defined as the elapsed time between suspension of the systemic circulation and the start of SCP, was close to significance (odds ratio, 1.9; p = 0.063).

In our series, the 30-day mortality rate was 8.8%. Preoperative renal failure (p = 0.034) and repeat thoracotomy for bleeding (p = 0.020) were found to be independent risk factors for early death. In the literature, the hospital mortality rate ranged from 0% in the series of Veeragandham and associates [19] to 25.2% in that of Hayashi and co-workers [20]. In a 1995 study, Kazui and colleagues [17] reported a hospital mortality rate of 16.1%. Similar results have been reported using DHCA with or without retrograde cerebral perfusion [2–8, 14, 16].

The drawback of SCP is that supraaortic vessels, which might be involved in an acute dissection, should be cannulated. Moreover, in the case of severe arteriosclerotic aneurysms, cerebral embolization could occur. No complications resulting from cannulation of supraaortic vessels were observed in our experience, or in that of Kazui and associates [17]. Careful deairing of the entire cerebral perfusion system is required, and care must be taken during introduction and positioning of the cannulas to prevent distal dissection of the supraaortic vessels or debridement of atherosclerotic plaques.

In conclusion, the results of this study are very encouraging. The mortality rate was similar to that obtained with other techniques, and no permanent neurologic deficits occurred. Postoperative outcomes (death and transient neurologic dysfunction) are not influenced by SCP time. We believe SCP is an optimal technique of cerebral protection. It extends the "safe" period of circulatory arrest and obviates the problems caused by deep hypothermia.

	References

Top Abstract Introduction Material and methods Results Comment References

 

1. Pierangeli A., Colì G., Mikus P.M., et al. Sostituzione dell’arco aortico in ipotermia profonda per aneurisma. Bull Scienze Med 1974;2:1-16.
2. Pierangeli A., Colì G., Donati A., Galli R., Mikus P.M., Turinetto B. Treatment of aortic arch aneurysm with deep hypothermia and circulatory arrest. J Cardiovasc Surg (Torino) 1975;16:409-414.[Medline]
3. Svensson L.G., Crawford E.S., Hess K.R., et al. Deep hypothermia with circulatory arrest. Determinants of stroke and early mortality in 656 patients. J Thorac Cardiovasc Surg 1993;106:19-31.[Abstract]
4. Crawford E.S., Svensson L.G., Coselli J.S., Safi H.J., Hess K.R. Surgical treatment of aneurysm and/or dissection of the ascending aorta, transverse aortic arch, and ascending aorta and transverse aortic arch. Factors influencing survival in 717 patients. J Thorac Cardiovasc Surg 1989;98:659-674.[Abstract]
5. Ergin M.A., Galla J.D., Lansman S.L., Quintana C., Bodian C., Griepp R. Hypothermic circulatory arrest in operations on the thoracic aorta. J Thorac Cardiovasc Surg 1994;107:788-799.[Abstract/Free Full Text]
6. Ueda Y., Miki S., Kusuhara K., Okita Y., Tahata T., Yamanaka K. Surgical treatment of aneurysm or dissection involving the ascending aorta and aortic arch, utilizing circulatory arrest and retrograde cerebral perfusion. J Cardiovasc Surg (Torino) 1990;31:553-558.[Medline]
7. Safi H.J., Brien H.W., Winter J.N., et al. Brain protection via cerebral retrograde perfusion during aortic arch aneurysm repair. Ann Thorac Surg 1993;56:270-276.[Abstract]
8. Yasuura K., Ogawa Y., Okamoto H., et al. Clinical application of total body retrograde perfusion to operation for aortic dissection. Ann Thorac Surg 1992;53:655-658.[Abstract]
9. Pagano D., Boivin C.M., Faroqui M.H., Bonser R.S. Retrograde perfusion through the superior vena cava perfuses the brain in human beings. J Thorac Cardiovasc Surg 1996;111:270-272.[Free Full Text]
10. Kazui T., Inoue N., Komatsu S. Surgical treatment of aneurysms of the transverse aortic arch. J Cardiovasc Surg (Torino) 1989;30:402-406.[Medline]
11. Kazui T., Inoue N., Yamada O., Komatsu S. Selective cerebral perfusion during operation for aneurysms of the aortic arch. Ann Thorac Surg 1992;53:109-114.[Abstract]
12. Pearce C.W., Weichert R.F., 3d, del Real R.E. Aneurysms of aortic arch. Simplified technique for excision and prosthetic replacement. J Thorac Cardiovasc Surg 1969;58:886-890.[Medline]
13. Kouchoukos N.T., Marshall W.G., Jr, Wedige-Stecher T.A. Eleven-year experience with composite graft replacement of the ascending aorta and aortic valve. J Thorac Cardiovasc Surg 1986;92:691-705.[Abstract]
14. Di Bartolomeo R., Giancola R., Pacini D., et al. Trattamento degli aneurismi dell’arco aortico in ipotermia profonda e arresto cardiocircolatorio. Minerva Chir 1997;52:89-94.
15. Loop F.D., Szabo J., Rowlinson R.D., Urbanek K. Events related to microembolism during extracorporeal perfusion in man. Ann Thorac Surg 1976;21:412-420.[Abstract]
16. Coselli J.S., Büket S., Djukanovic B. Aortic arch operation. Ann Thorac Surg 1995;59:19-27.[Abstract/Free Full Text]
17. Kazui T., Kimura N., Komatsu S. Surgical treatment of aortic arch aneurysms using selective cerebral perfusion. Experience with 100 patients. Eur J Cardio-thorac Surg 1995;9:491-495.[Abstract]
18. Bachet J., Guilmet D., Goudot B., et al. Cold cerebroplegia. A new technique of cerebral protection during operations on the transverse aortic arch. J Thorac Cardiovasc Surg 1991;102:85-94.[Abstract]
19. Veeragandham R.S., Hamilton I.N., Jr, O’Connor C., Rizzo V., Najafi H. Experience with antegrade bihemispheric cerebral perfusion in aortic arch operations. Ann Thorac Surg 1998;66:493-499.[Abstract/Free Full Text]
20. Hayashi J-i, Eguchi S., Yasuda K., et al. Aortic arch operation using selective cerebral perfusion for nondissecting thoracic aneurysm. Ann Thorac Surg 1997;63:88-92.[Abstract/Free Full Text]

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