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Ann Thorac Surg 2003;75:514-519
© 2003 The Society of Thoracic Surgeons

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Original article: cardiovascular

Surgery for acute type A dissection using antegrade selective cerebral perfusion: experience with 122 patients

^a Department of Cardiopulmonary Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
^b Department of Cardiac Surgery, Policlinico Sant’Orsola, University of Bologna, Bologna, Italy

Accepted for publication August 21, 2002.

* Address reprint requests to Dr Di Eusanio, Department of Cardiopulmonary Surgery, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
e-mail: m_dieus{at}hotmail.com

	Abstract

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BACKGROUND: Antegrade selective cerebral perfusion (ASCP) has proved to be a reliable method of brain protection during surgery of the thoracic aorta, but its use during aortic dissection surgery still remains controversial. In this study, we present our results after the operative repair of acute type A aortic dissections using ASCP and moderate hypothermic circulatory arrest.

METHODS: Between October 1995 and August 2001, 122 patients (76 men, 46 women) underwent repair of acute type A aortic dissection with the aid of ASCP and open distal anastomosis. The average age of the patients was 61 ± 12 (mean ± standard deviation). Preoperative complications included cardiac tamponade (n = 34; 27.0%), aortic regurgitation (n = 27; 22.1%), and new neurological deficits (n = 11; 9%).

RESULTS: Stepwise logistic regression revealed preoperative cardiac tamponade (p = 0.018) and new neurological deficits (p = 0.017) to be independent determinants for hospital mortality (19.7%). Permanent neurological complications occurred in 7% of the patients. Independent risk factors for temporary neurological dysfunction (11.2%) included cardiac tamponade (p = 0.019) and preoperative neurological deficits (p = 0.000).

CONCLUSIONS: In our experience, the surgical treatment of acute type A aortic dissection with the aid of ASCP was associated with acceptable hospital mortality and neurologic morbidity rates.

	Introduction

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Despite the fact that several advances in preoperative recognition, intraoperative techniques, and postoperative care have been achieved in recent years, the treatment of acute type A aortic dissection is still associated with considerable mortality and morbidity rates [1–4]. Antegrade selective cerebral perfusion (ASCP) has proved to be a reliable method of brain protection during surgery of the thoracic aorta [5–8]. However, since manipulation and cannulation of the arch vessels are required, its use during aortic dissection repair is still debated. The purpose of this study was to review our experience with 122 consecutive patients undergoing surgery for acute type A aortic dissection with the aid of ASCP and to determine the risk factors associated with hospital mortality and adverse neurological outcome.

	Material and methods

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Patients
Between October 1995 and August 2001, 122 patients underwent surgical repair of acute type A aortic dissection with the aid of ASCP, moderate hypothermia, and open distal anastomosis at St. Antonius Hospital (Nieuwegein, The Netherlands) and Sant’Orsola Hospital (Bologna, Italy). Medical records were reviewed for clinical variables including preoperative status, intraoperative data, and early postoperative complications. Patients referred for chronic dissections were excluded from the study.

Seventy-six men (62.3%), and 46 women (37.7%) having a mean age of 61.2 ± 11.2 years (range 27 to 81 years) were enrolled in the study. All patients had precordial, back, or abdominal pain at the onset of symptoms. Cardiac tamponade (n = 34, 27%), new neurological deficits (n = 11, 9%), aortic valve insufficiency (n = 27, 22.1%), and arterial hypertension (n = 52, 42.6%) were the most common preoperative findings (Table 1). Preliminary diagnosis at the referring institutions was usually made by means of echocardiography, computed tomographic scan or, occasionally, by angiography. To prevent further delay, it is the policy of our institutions to immediately transfer the patient to the operating room where a transesophageal echocardiogram is performed under anesthesia for final diagnostic confirmation.

Operative technique
A median sternotomy was used in all 122 cases. After systemic heparinization, cardiopulmonary bypass (CPB) was performed using a cannula for arterial return in the femoral artery having the best pulsation and a venous single two-stage cannula in the right atrium. The left side of the heart was vented through the right superior pulmonary vein. Myocardial protection was obtained by means of antegrade or retrograde infusion of cold crystalloid cardioplegia and topical pericardial cooling.

Details of our cannulation technique and method of ASCP with moderate hypothermic circulatory arrest have been previously described [9, 10]. Briefly, after the cardiopulmonary bypass was instituted and the patients were cooled to a nasopharyngeal temperature of 22° to 26°C (usually within 30 minutes), systemic circulation was arrested and the aorta opened. With the patient in the Trendelenburg position, two 15 F retrograde coronary sinus perfusion cannulas (Medtronic DLP; 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 (Baxter Health Care, Irvine CA; IFM, Clearwater, FL) in order to avoid the steal phenomenon.

Cerebral perfusion was started at a rate of 10 ml/min/kg and adjusted to maintain a right radial arterial pressure between 40 and 70 mm of Hg. During open distal anastomosis [11, 12], blood perfusion to the lower half of the body from the femeral artery was discontinued. After the distal anastomosis was performed, the proximal graft was cross-clamped and extracorporeal circulation was reinstituted in an antegrade manner through a side branch of the prosthesis.

The intimal tear was always resected if located in the ascending aorta or in the transverse arch; the false lumen was occluded with a monofilament suture using a Teflon (C.R. Bard, Tempe, AZ) felt, gelatine-resorcinol-formaldehyde glue (GRF-glue, Fii, Sain-Just-Malmont, France) or fibrinous glue (Tissue-col, Immuno AG, Vienna, Austria) to reinforce the proximal and distal anastomotic sites. The reconstructive material was placed between the dissected aortic layers. The extent of the replacement, determined by the intimal tear location, and the associated procedures are summarized in Table 2.

Statistical analysis
Continuous variables were expressed as mean ± 1 standard deviation, and categorical variables were expressed as percentages. All preoperative and intraoperative variables (Table 1) were first analyzed using univariate analysis (unpaired two-tailed t test, ² test or Fisher’s exact test when appropriate) to determine whether any single factor influenced hospital mortality and neurologic outcome; p < 0.05 was considered to indicate statistical significance. Variables which had p < 0.05 in the univariate analysis were examined using multivariate analysis by forward stepwise logistic regression in order to evaluate independent risk factors for hospital mortality, permanent neurological dysfunction, and transient neurological dysfunction.

The analysis for permanent neurological dysfunction (stroke or coma) and transient neurological dysfunction (postoperative confusion, agitation, delirium, prolonged obtundation, or transient parkinsonism with negative brain computed tomography scanning and complete resolution before discharge) were conducted separately. Risk factors for permanent neurological dysfunction were examined in all patients who survived the operation long enough to undergo neurological evaluation. Risk factors for transient neurological dysfunction were assessed in all operative survivors without permanent neurological dysfunction. Statistical analysis was performed using SPSS 10.0 statistical software (SPSS Inc, Chicago, IL).

	Results

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Cardiopulmonary bypass data
The mean CPB time was 198 ± 74 minutes (range 85 to 493 minutes) and the mean myocardial ischemic time was 115 ± 54 minutes (range 28 to 267 minutes). The mean ASCP time was 55 ± 27 minutes (range 19 to 150 minutes). Sixty-five patients (53.3%) had an ASCP time of more than 45 minutes, and 36 (29.5%) of more than 60 minutes (Fig 1). The mean lowest nasopharyngeal and rectal temperatures were 23.2° ± 2.6°C and 26.1° ± 3.5°C, respectively. The mean lowest blood temperature was 18.1° ± 3.0°C.

View larger version (50K): [in this window] [in a new window]   Fig 1. Distribution of patients by selective cerebral perfusion time. (ASCP = antegrade selective cerebral perfusion.)

Using multivariate analysis, preoperative new neurologic deficits (p = 0.017; OR = 5.6) and cardiac tamponade (p = 0.018; OR = 5.6) were indicated to be independent determinants for hospital mortality (Table 3). Failure to resect the intimal tear as well as prolonged CPB and ASCP times had no impact on hospital mortality (Table 1).

Permanent neurological dysfunction occurred in 8 patients (7%). No predictive risk factors for permanent neurological dysfunction were identified by multivariate analysis. Transient neurological dysfunction occurred in 12 of the 107 survivors without permanent neurological dysfunction (11.2%). Stepwise logistic regression indicated preoperative new neurological deficits (p = 0.000; OR = 14.6) and cardiac tamponade (p = 0.019; OR = 5.4) to be independent predictors of transient neurological dysfunction (Table 3). Failure to resect the intimal tear as well as prolonged CPB and ASCP times were not statistically associated with an increased risk of permanent or transient neurological complications (Table 2).

Other postoperative complications included renal insufficiency requiring dialysis in 11 patients (9%), respiratory insufficiency requiring mechanical ventilatory support of more than 5 days in 27 (22.1%), acute myocardial infarction in 7 (5.7%), and bleeding requiring a rethoracotomy in 17 (13.9%).

	Comment

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Although the surgical outcome in patients with acute type A aortic dissection has substantially improved in recent years, mortality and morbidity rates are still considerably high [1–4]. In our high-risk group of patients (Table 1), the hospital mortality, permanent neurological dysfunction, and transient neurological dysfunction rates were 19.7%, 7%, and 11.2%, respectively. Multivariate analysis indicated only preoperative conditions, namely new neurological deficits and cardiac tamponade, to be independent predictive risk factors for hospital mortality and transient neurological dysfunction. None of the variable analyzed were statistically correlated with an increased risk of permanent neurological dysfunction.

It has been demonstrated that a deep hypothermic circulatory arrest time of more than 30, 45, and 60 minutes is associated with increasing risk of transient neurological dysfunction, stroke, and mortality, respectively [14, 15]. Therefore, in our series, only 11 patients (9%), who had an ASCP time of less than 30 minutes, could have been treated by means of deep hypothermic circulatory arrest within the safe time limit. Sixty-five patients (53.3%) had an ASCP time of more than 45 minutes, and 36 (29.5%) of more than 60 minutes (Fig 1). In this study, which confirms our previous findings [6, 8–10], the duration of ASCP did not affect hospital mortality and neurological outcome.

By means of ASCP, the time of circulatory arrest can be safely prolonged as compared to deep hypothermic circulatory arrest with or without retrograde cerebral perfusion, allowing more complex repairs to be performed [7]. This seems to be very important especially in the case of acute aortic dissection repair, permitting unhurried and accurate reconstruction of the friable aortic tissue or more extended aortic replacement.

Recent reports [16–21] indicate a higher risk of early mortality when simultaneous aortic arch replacement is performed, ranging from 20% to 55%. In a recent study, Kazui et al. [22] reported a hospital mortality of 21% in a selected group of 70 patients with acute type A aortic dissection undergoing complete aortic arch replacement with the aid of ASCP. In our series, simultaneous aortic arch replacement was performed on 20 patients (16.7%) with a hospital mortality rate of 20% (4/20). The extent of the replacement did not affect either hospital mortality or neurological outcome.

The technical complexity and a cumbersome operative field, as well as manipulation and cannulation of the arch vessels which might be involved in the dissection, are considered as possible drawbacks of ASCP. Preparation and insertion of the ASCP catheters take less than 2 minutes in experienced hands. Our ASCP cannulas are flexible and can be easily placed towards the patient’s head so as not to obscure the operating field. Furthermore, they are connected to the oxygenator through a separate single roller pump allowing separate control of systemic and cerebral perfusions. Cannulation of the arch vessels, especially in case of acute dissection, is certainly a delicate maneuver, and great care has to be taken. However, in our series, no cannulation-related complications occurred. It was always possible to distinguish, throughout the aortotomy, the true lumen of the arch vessels and to perform, under direct visualization, a safe cannulation. If the arch vessels are involved in the dissection and simultaneous aortic arch replacement is performed, the "separated graft technique" [22] can be used to reimplant the supra-aortic vessels. This provides an important advantage, that is, the anastomotic sutures are placed more distally on the arch vessels to which point the dissection does not usually extend.

In our series, no spinal cord injuries occurred after surgery. The mean circulatory arrest time was 55 ± 27 minutes, and the mean nasopharyngeal and rectum temperatures were 23° and 26°C, respectively. This proves that when ASCP and moderate hypothermia are employed, it is safe to stop body circulation for about 60 minutes. Using ASCP, spinal cord perfusion may continue through the right subclavian and right vertebral arteries, as well as through the blocked left subclavian and left vertebral arteries. This probably underscores the value of ASCP and the importance of blocking the left subclavian artery.

Cerebral monitoring plays a central role during aortic dissection repair. The installation requires only a few minutes and malpositioning of the ASCP system as well as cerebral malperfusion at the institution of CPB can be easily and immediately detected. If cerebral malperfusion occurs during the cooling period, either a different arterial inflow site can be selected or, alternatively, if the patient’s temperature is already low enough, circulatory arrest and ASCP can be promptly instituted.

In summary, during surgery of acute type A aortic dissection, ASCP with moderate hypothermia provided reliable brain protection, even in the longer periods of circulatory arrest which are anticipated in this complex form of aortic surgery. ASCP is technically feasible, and resulted in low neurologic complication rate and acceptable hospital mortality.

	References

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Marc A.A.M. Schepens Karl M. Dossche Roberto Di Bartolomeo Angelo Pierangeli Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Di Eusanio, M. Articles by Morshuis, W. J. Search for Related Content PubMed PubMed Citation Articles by Di Eusanio, M. Articles by Morshuis, W. J. Related Collections Great vessels