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Ann Thorac Surg 2001;71:1062-1063
© 2001 The Society of Thoracic Surgeons

Update

Update: Brain protection via cerebral retrograde perfusion during aortic arch aneurysm repair

Hazim J. Safi, MDa, Pavel V. Petrik, MDa, Charles C. Miller, PhD, IIIa

a Department of Cardiothoracic and Vascular Surgery, The University of Texas Houston-Medical School, Memorial Hermann Hospital, Houston, Texas, USA

Address reprint requests to Dr Safi, Department of Cardiothoracic and Vascular Surgery, The University of Texas Houston-Medical Center, Memorial Hermann Hospital, 6410 Fannin St, Suite 450, Houston, TX 77030
e-mail: hazim.j.safi{at}uth.tmc.edu

As Originally Published in 1993:



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In 1993, we reported our experience with retrograde cerebral perfusion (RCP) and profound hypothermia and the brain protection provided by these adjuncts in aortic arch aneurysm surgery [1]. At that time, we had accumulated a series of 11 patients and felt that clinical results warranted continued use of the technique. During the same period, we conducted a study in a swine model that also demonstrated a high degree of efficacy in RCP [2]. In 1997, having used RCP in 161 patients, we published another report that further described the adjunct’s clinical utility [3]. Seven years after our initial report in The Annals of Thoracic Surgery, we continue to use RCP. Our experience, now grown from 11 to 266 cases, supports our original conclusions that RCP decreases the incidence of stroke in aortic arch repair.

Three hundred seven patients with aneurysms of the aortic arch were treated by the senior author between January 1991 and May 1999. We integrated RCP into our regular ascending/arch protocol in February 1992. For the current brief update, we compared the results of 41 non-RCP cases treated before February 1992 to 266 RCP cases after this date. Four strokes occurred within 30 days after operation in the 41 patients who did not receive RCP (9.5%), compared with three in the 266 who received RCP (1.1%). Odds ratio for stroke in the RCP group was 0.11 (p < 0.001). No other variable other than RCP was a significant predictor of stroke risk. Pump time is no longer statistically significant. The loss of statistical significance in the pump time, which was once a major risk factor for stroke, indicates that RCP greatly improves the tolerance of the brain to extensive aortic arch repair.

As for the original 11 patients in our first report, 3 have died (1 at 4 months from respiratory failure, 1 at 14 months from multisystem organ failure, and 1 from a ruptured thoracoabdominal segment 4 years after the arch replacement). Eight patients were alive at the last follow-up (4 to 6 years postoperatively). Three patients who wrote to us recently described themselves as "active," "leading a full life," and "healthy."

One of the several vexing problems that remains in aortic arch replacement surgery is that of neurocognitive sequelae after treatment. Only anecdotal reports describing this problem have appeared in the literature thus far. Formal neuropsychological evaluation before and after surgery, along with a correlation of the findings to patient characteristics or intraoperative variables, deserves future investigation.

References

  1. 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]
  2. Safi H.J., Iliopoulos D.C., Gopinath S.P., et al. Retrograde cerebral perfusion during profound hypothermia and circulatory arrest in pigs. Ann Thorac Surg 1995;59:1107-1112.[Abstract/Free Full Text]
  3. Safi H.J., Letsou G.V., Iliopoulos D.C., et al. Impact of retrograde cerebral perfusion on ascending aortic and arch aneurysm repair. Ann Thorac Surg 1997;63:1601-1607.[Abstract/Free Full Text]



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