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Ann Thorac Surg 2002;74:S1806-S1809
© 2002 The Society of Thoracic Surgeons
a First Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
* Address reprint requests to Dr Kazui, First Department of Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Hamamatsu, Japan, 431-3192
e-mail: tkazui{at}hama-med.ac.jp
Presented at the Aortic Surgery Symposium VIII, May 2–3, 2002, New York, NY.
Abstract
BACKGROUND: To evaluate the safety and usefulness of antegrade selective cerebral perfusion (SCP) during arch aneurysm or aortic dissection operations.
METHODS: Between January 1986 and December 2001, 330 patients underwent aortic arch repair using SCP. Operations were performed with the aid of hypothermic extracorporeal circulation, SCP, and systemic circulatory arrest in most cases. In all, 89 patients (27%) were operated on for acute aortic dissection, 77 (23%) for chronic aortic dissection, and 164 (50%) for degenerative aneurysm. Total arch replacement using a branched graft was performed in 288 patients (94%). Mean SCP time was 86.2 ± 28.5 minutes.
RESULTS: The overall in-hospital mortality rate was 11.2% (falling to 3.2% in the 124 patients operated on between 1997 and 2001). Independent determinants of hospital mortality were pump time, renal/mesenteric ischemia, chronic renal failure, increasing age, period of operation, and nonuse of four-branched arch graft. The overall postoperative incidences of temporary and permanent neurologic dysfunction were 4.2% and 2.4%, respectively. There was no significant correlation between SCP time and in-hospital mortality or neurologic outcome.
CONCLUSIONS: Selective cerebral perfusion is a reliable technique for cerebral protection and it facilitates complex and time-consuming total arch replacement.
It is well known that appropriate selection of cerebral protection methodology during aortic arch exclusion has a substantial influence on the surgical outcome of aortic arch aneurysm or dissection. Antegrade selective cerebral perfusion (SCP) has been the cerebral protection method of choice in our institute, particularly in cases of aortic arch disease requiring complicated and time-consuming aortic arch repair [1–3]. The aim of the present study was to evaluate the safety and usefulness of SCP during arch aneurysm or aortic dissection operations.
Material and methods
Three hundred and thirty patients underwent surgery for aortic arch disease using hypothermic cardiopulmonary bypass (CPB) and SCP between January 1986 and December 2001. The study patients ranged in age from 18 to 91 years with a mean of 62.9 ± 12.7. Two hundred and twenty (67%) of the patients were male and 110 (33%) were female. Eighty-nine patients (27%) were treated for acute aortic dissection, 77 (23%) for chronic dissection, and 164 (50%) for degenerative aneurysm. Ninety-nine (30%) patients underwent emergency operation within 24 hours of admission.
Preoperative complications included shock in 30 (9%); chronic obstructive pulmonary disease (presence of chronic bronchitis, pulmonary emphysema or FEV1 <70%) in 29 (9%); chronic renal dysfunction (creatinine level >3 mg/dL) in 36 (11%) with 8 requiring hemodialysis; cerebral infarct in 26 (8%), and coronary artery disease in 50 (15%). Aortic dissection-related complications included cardiac tamponade in 42 (13%), myocardial ischemia in 9 (3%), cerebral ischemia in 10 (3%), renal/mesenteric ischemia in 11 (3%), and leg ischemia in 11 (3%). Sixty patients (18%) had undergone a total of 68 previous cardiovascular procedures.
Preoperative aortography or digital subtraction angiography and contrast computed tomography (CT) were performed in most patients undergoing elective procedures.
Operative technique
Operations were performed through a median sternotomy in 326 patients (99%) and through a median sternotomy and left anterior thoracotomy in 4 (1%) for extended descending aortic replacement (DAR). As for the site of arterial cannulation for CPB, the ascending aorta, and the right axillary artery if necessary, were used in most of the recent cases. The details of hypothermic CPB and antegrade SCP have been described previously [1–3]. Briefly, when the patient was cooled by extracorporeal circulation to a rectal temperature of 22C, SCP cannulas were inserted into the innominate and left common carotid arteries. SCP was then started at the rate of 10 mL · kg-1 · min-1 using a single pump. The left subclavian artery was kept clamped during SCP. The cerebral perfusion pressure was adjusted to maintain a right radial artery pressure of 40 to 70 mm Hg. During CPB arterial blood pH was managed according to the 
-stat strategy. An open distal anastomosis was used in 321 patients (97%) since March 1987. Real time intraoperative monitoring of SCP included cerebral perfusion pressure and flow, two-channel serial electroencephalography, two-channel near infrared spectroscopy, and internal jugular venous oxygen saturation.
Operative techniques used in this series are listed in Table 1. Patch angioplasty of the aortic arch was used in the initial 3 patients (1%) and graft replacement in the remaining 326 (99%). With regard to the extent of graft replacement, ascending aortic replacement (AAR) and hemiarch or partial arch replacement (HAR) were performed in 18 patients (5%); AAR and total arch replacement (TAR) in 126 (38%); TAR in 12 (4%); TAR and descending aortic replacement (DAR) in 10 (3%), and AAR, TAR, and DAR in 160 (49%). A concomitant elephant trunk technique with TAR was performed in 40 patients. For TAR, the en bloc repair technique—in which the arch vessels are reconstructed in an island fashion—was used in the initial 21 patients (6%). In the remaining 287 patients (94%), the separated graft technique was used: the aortic arch and arch vessels were replaced with a branched graft (an arch graft with 3 limbs in the first 51 patients, and one with 4 limbs in the remaining 235 patients after April 1993). One hundred and eighteen patients (36%) had 130 concomitant procedures that are summarized in Table 1.
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The overall in-hospital mortality rate was 11.2% (37 of 330 patients). In-hospital mortality in the early series (between 1986 and 1996) comprising 206 patients was 16.0% whereas that in the late series (between 1997 and 2001) comprising 124 patients was 3.2% (p < 0.001). Table 2 shows the independent determinants of in-hospital death as estimated by multivariable step-wise logistic regression analysis. It revealed that pump time, renal/mesenteric ischemia due to aortic dissection, chronic renal failure, increasing age, early series, and nonuse of a four-branched arch graft were significant independent predictors of in-hospital mortality.
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Mean SCP time was 86.2 ± 28.5 minutes. There was no significant correlation between SCP time and in-hospital mortality or neurologic outcome. Survival rate including in-hospital mortality for all patients was 80.4% ± 2.3% and 75.7% ± 2.8% at 5 and 10 years after the operation, respectively.
Comment
The cerebral protection methods currently used for aortic arch surgery are profound hypothermic circulatory arrest (HCA) with or without retrograde cerebral perfusion (RCP), and antegrade SCP. Each technique has its own advantages and disadvantages. Our previous experimental study suggested that among the three techniques, antegrade SCP was the safest for a cerebral protection time more than 90 minutes. That is mainly because SCP supplies sufficient oxygenated blood to the brain in an antegrade fashion. A complicated TAR usually requires a cerebral protection time of 60 to 90 minutes in our hands. Therefore, antegrade SCP has been the cerebral protection method of choice for TAR in our institute.
Although antegrade SCP has been considered a cumbersome procedure, we have managed to simplify the technique by perfusing two arteries using one pump and also by developing a new flexible cerebral perfusion cannula [5] that can be used without obscuring the operative field. We can avoid cannulation-related complications even in acute dissection cases by safely cannulating the true lumen through the arteriectomy site. Postoperative permanent neurologic dysfunction after an aortic arch operation usually results from cerebral emboli and may have nothing to do with the cerebral protection method [6, 7]. Therefore, we usually cannulate the ascending aorta or right axillary artery for instituting CPB and initiate antegrade perfusion through the side branch of the arch graft after distal graft anastomosis to reduce embolization from the distal aorta.
It has been suggested that the presence of clot or atheroma in the aorta is a determinant of stroke during aortic arch aneurysm repair [7]. Therefore we prefer to perform complete resection of the ascending aorta and aortic arch in which clot or atheroma are present, even in the absence of an aneurysm. Patch angioplasty or HAR were performed in the early period of this series and are now carried out using HCA with or without RCP.
For TAR an en bloc repair technique was used in the initial cases and a separate graft technique in the most recent cases. The latter technique has several advantages: (1) in aged patients atherosclerotic lesions near the origin of the arch vessels can be completely resected; (2) in patients with acute dissection, graft anastomosis can be performed at the intact distal site of the arch vessel where dissection has not extended; (3) in Marfan’s patients the pathologic portion of the aortic arch can be completely resected, and (4) bleeding from the arch vessel anastomosis can easily be controlled.
We performed TAR using SCP in selected patients with acute type A aortic dissection with the expectation of achieving a reduction in the risk of late reoperation related to dissection or the facilitation of late reoperation through a left thoracotomy, which would eventually improve late results [2]. Using SCP combined with systemic circulatory arrest we became more aggressive, extending distal aortic replacement to the descending aorta and found that it did not increase mortality. We can reach the proximal descending aorta through a median sternotomy alone; the middescending aorta by opening the left mediastinal pleura and the distal descending aorta through a left thoracotomy.
The average SCP time was 86 minutes in our series and it had no significant correlation with in-hospital mortality or neurologic outcome. Our 2.5% permanent neurologic dysfunction rate is comparable with the 0% to 11% in previous reports [6–14]. The 4.2% incidence of temporary neurologic dysfunction in the present series and the 5.3% to 5.4% in other previous reports on SCP [13, 14] are markedly lower than the 20% to 25% rates in other series where HCA with or without RCP have been used [7, 12].
In summary, SCP is a reliable technique for cerebral protection during repair of aortic arch aneurysm or dissection and it facilitates complex and time-consuming total arch replacement.
References
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