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Ann Thorac Surg 2003;75:266-268
© 2003 The Society of Thoracic Surgeons

Case report

Isolated cerebral perfusion for intraoperative cerebral malperfusion in type A aortic dissection

Johji Fukada, MD, PhDa*, Kiyofumi Morishita, MD, PhDa, Nobuyoshi Kawaharada, MD, PhDa, Akihiko Yamauchi, MDa, Takeo Hasegawa, CEa, Takuma Satsu, MDa, Tomio Abe, MD, PhDa

a Department of Cardiothoracic Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan

Accepted for publication August 9, 2002.

* Address reprint requests to Dr Fukada, Department of Cardiothoracic Surgery, Sapporo Medical University School of Medicine, South-1, West-12, Chuo-ku, Sapporo 0608543, Japan
e-mail: atsfukada{at}yahoo.co.jp


   Abstract
Top
 Abstract
Introduction
 Comment
 References
 
Cerebral malperfusion due to expansion of a false lumen can occur acutely during aortic repair when retrograde femoral perfusion is initiated. We detected this catastrophe by a rapid decrease in regional cerebral oxygenation and successfully treated it by immediate isolation of the cerebral circulation from the systemic circulation. The surgical management, including the above technique, for this rare event is described.


   Introduction
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 Abstract
 Introduction
Comment
 References
 
Stroke as a result of malperfusion of the arch branches is associated with a high early mortality rate in patients with acute type A aortic dissection [1]. Extracorporeal circulation through the femoral artery can create a special situation of cerebral malperfusion during aortic repair by expansion of a false lumen. We describe such a case that was successfully treated by an isolated cerebral circulation separated from systemic circulation by immediate application of antegrade selective cerebral perfusion (SCP). The treatment options for this unusual event during an operation are discussed.

A 71-year-old woman was admitted to our hospital after sudden onset of anterior chest pain and loss of consciousness. On arrival the patient was conscious. Her left arm was pale and pulseless while normal pulsation was palpable in the right radial artery, bilateral femoral arteries, and bilateral carotid arteries. An enhanced chest computed tomography scan displayed a type A aortic dissection with a narrowed true lumen in the ascending aorta. Both the axillary arteries, the left carotid artery, and the left iliac artery were involved in dissection.

The patient was referred for urgent surgery 7 hours after the onset. Blood pressure was continiously monitored using the left radial artery and the left dorsal pedis artery. To estimate the state of regional cerebral oxygenation (rSo2), two spectrophotometer probes (INVOS4100; Somanetics, Troy, MI) were attached to the bilateral forehead with adhesive and rubber straps, with rSo2 being recorded throughout the procedure (Fig. 1). Spectroscopy enables hemoglobin oxygen saturation in brain tissue to be monitored. Cables deliver near-infrared light to the patient through a patch placed on the forehead. Light entering the tissue is absorbed or scattered and portions of it pass back through the surface near the entry point. Because hemoglobin and oxyhemoglobin have unique absorption profiles the ratio of the two can be calculated and the percent of oxyhemoglobin can be expressed as saturation. The instrumentation can contininuously graph percent saturation versus time for a continuous reading. The normal value of rSo2 ranges from 57% to 75%.



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  		Fig 1. Changes in (top) regional cerebral oxygenation (rSo2) and (bottom) rectal and right tympanic temperatures during cardiopulmonary bypass (CPB). Solid circles = right INVOS; open circles = left INVOS; open squares = perfused blood temperature; shaded squares = rectal temperature; solid squares = right tympanic temperature. (INVOS = spectrophotometer probes; SCP = selective cerebral perfusion.)

 
The right femoral artery was exposed for arterial cannulation because it was the only artery that was not involved in aortic dissection. The heart, ascending aorta, aortic arch, and arch vessels were exposed through median sternotomy. After positioning of a single two-stage cannula for venous drainage in the right atrium the patient was placed on cardiopulmonary bypass (CPB) and was cooled down. Several minutes after the initiation of CPB both the rSo2 values decreased to 31% and 24% respectively while the left radial artery pressure was 56/44 mm Hg. These rapid decreases in rSo2 indicated the possibility of cerebral ischemia due to expansion of a false lumen in the bilateral carotid arteries. The innominate and left carotid arteries were cross-clamped proximally and were transected. The true lumen of the innominate and left carotid arteries were cannulated through arteriectomies and SCP was started, resulting in an immediate recovery of the bilateral rSo2. The right tympanic temperature started to fall as soon as the SCP had been initiated (Fig 1). SCP using a single roller pump separated from the systemic circulation was performed at the rate of (10 mL · µg-1 · min-1) throughout the period of cerebral perfusion at a blood temperature ranging from 18°C to 36°C, which was dependent on that in the main CPB circuit. When the patient was cooled to a rectal temperature of 22°C the ascending aorta was cross-clamped proximally to the innominate artery and the ascending aorta was incised. There was a large entry across the posterior side of the ascending aorta. Myocardial protection was provided with cold blood cardioplegia. First, proximal repair was performed using an external Teflon felt strip at the level of the sinotubular junction. Then the systemic circulation was arrested and the aortic arch was inspected. Another intimal tear was not found inside the arch and resection of the aortic arch was therefore not considered to be neccessary. Distal graft anastomosis was performed using a Hemashield woven vascular prosthesis with four limbs proximally to the innominate artery. The graft (Meadox Medicals, Inc, Oakland, NJ) was cross-clamped proximally and antegrade extracorporeal circulation was started from the fourth branch together with rewarming. The innominate artery and the left carotid artery were anastomosed to respective limbs of the graft and SCP was terminated. The third and fourth limbs were resected and the proximal ends of the innominate artery and the left carotid artery were ligated. The patient regained consciousness without any derilium 4 hours after the end of operation. She was discharged 30 days after surgery on foot.


   Comment
Top
 Abstract
 Introduction
 Comment
References
 
The frequency of involvement of arch branches in aortic dissection has been reported to range from about 5% to 46% [2]. The most common mechanism leading to cerebral ischemia is obstruction of the innominate or the left common carotid artery by expansion of a false lumen within the ascending aorta in the absence of distal reentry [1]. On the other hand a special form of expansion of a false lumen can occur acutely during aortic repair with retrograde femoral perfusion [3].

Even though axillary artery cannulation has been recommended for the surgical treatment of type A aortic dissection [4], we had to use the right femoral artery for arterial cannulation because of the existence of dissection inside both axillary arteries. In such a case if a torn dissecting membrane at the distal reentry acts as a flap-valve, retrograde femoral perfusion can expand the false channel, leading to cerebral ischemia. Although parallel recording of the radial versus femoral arterial pressures was reported to be useful to detect such a catastrophe [5], a significant difference between the left radial and femoral arterial pressures was not found until the initiation of SCP despite the abnormality of rSo2 in our patient. The probable explanation for these observations is that the blood flow was preserved in the left axillary artery but was obstructed in the other two arch branches.

Somatosensory evoked potential (SEP) has been used in cardiovascular procedures as a means of monitoring the central nervous system. However, the latency is prolonged and the amplitude decreases when the brain temperature is lowered. Furthermore, it takes 5 to 15 minutes by SEP from the shutting off of the cerebral blood flow to the complete disappearance of the amplitude at a brain temperature of 25°C [6]. INVOS can immediately reveal a shortage of the oxygen requirement in the brain tissue. Moreover the system of INVOS is much simpler than that of SEP and it can be set up even in the middle of an emergency operation.

Shiiya and coworkers [7] recommended that SCP be established before manipulation of the arch to reduce the risk of atheroembolism to the brain in the surgical treatment of arteriosclerotic arch aneurysms. Their technique for SCP consisted of direct cannulations to the innominate artery and the left common carotid artery. However Imanaka and colleagues [8] recently reported a fatal intraoperative dissection of the innominate artery due to SCP through the right axillary artery in a patient with acute type A aortic dissection. Retrograde perfusion from the axillary artery with proximal clamping of the innominate artery may worsen a dissection in the innominate artery and the right carotid artery. We inserted the cannula for SCP directly into the true lumens through the arteriectomies and this antegrade manner was expected to be superior to direct cannulation of the axillary artery.

Based on the experience of our case an INVOS cerebral oximeter is useful for the accurate detection of an unsuspected cerebral ischemia. Prompt initiation of SCP, which should be performed through arteriectomies, is important for preventing cerebral damage when cerebral malperfusion is strongly suspected. Once the brain has been protected antegrade systemic perfusion should be started as early as possible to minimize the duration of systemic organ malperfusion.


   References
Top
 Abstract
 Introduction
 Comment
 References
 

  1. Borst H.G., Heinemann M.K., Stone C.D. Organ ischemia. Surgical treatment of aortic dissection. Edinburgh: Churchill Livingstone, 1996:249-272.
  2. Fann J.I., Sarris G.E., Miller D.C., et al. Surgical management of acute aortic dissection complicated by stroke. Circulation 1989;80:1257-1263.
  3. Robicsek F., Guarino R.L. Compression of the true lumen by retrograde perfusion during repair of aortic dissection. J Cardiovasc Surg 1985;26:36-40.[Medline]
  4. Neri E., Massetti M., Capannini G., et al. Axillary artery cannulation in type A aortic dissection operations. J Thorac Cardiovasc Surg 1999;118:324-329.[Abstract/Free Full Text]
  5. Borst H.G., Laas J., Heinemann M. Type A aortic dissection: diagnosis and management of malperfusion phenomena. Semin Thorac Cardiovasc Surg 1991;3:238-241.[Medline]
  6. Tanaka H., Kazui T., Sato H., Inoue N., Yamada O., Komatsu S. Experimental study on the optimum flow rate and pressure for selective cerebral perfusion. Ann Thorac Surg 1995;59:651-657.[Abstract/Free Full Text]
  7. Shiiya N., Kunihara T., Imamura M., Murashita T., Matsui Y., Yasuda K. Surgical management of atherosclerotic aortic arch aneurysms using selective cerebral perfusion: 7-year experience in 52 patients. Eur J Cardio Thorac Surg 2000;17:266-271.[Abstract/Free Full Text]
  8. Imanaka K., Kyo S., Tanabe H., Asano H., Yokote Y. Fatal intraoperative dissection of the innominate artery due to perfusion through the right axillary artery. J Thorac Cardiovasc Surg 2000;120:405-406.[Free Full Text]



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This Article
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Tomio Abe
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