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Ann Thorac Surg 2004;78:591-595
© 2004 The Society of Thoracic Surgeons

Original article: cardiovascular

Neurocognitive functions after aortic arch repair with right brachial artery perfusion

Mehmet Ali Özatik, MDa*, Seref A. Küçüker, MDa, Hicran Tülüceb, Ahmet Sartias, MDa, Erol sener, MDa, Sirel Karakas, PhDc, Oguz Tasdemir, MDa

a Cardiovascular Surgery Clinic, Ankara, Turkey
b Psychology Department, Hacettepe University, Türkiye Yüksek htisas Hospital, Ankara, Turkey
c Experimental Psychology, Hacettepe University, Ankara, Turkey

Accepted for publication January 9, 2004.

* Address reprint requests to Dr Özatik, Türkiye Yüksek htisas Hastanesi, Kalp ve Damar Cerrahisi Klinii, 06100, Shihiye, Ankara, Turkey
e-mail: maozatik{at}yahoo.com


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 Acknowledgments
 References
 
BACKGROUND: Satisfactory neurologic outcome following aortic arch repair through right brachial artery perfusion is well established. However, how neurocognitive functions are affected following selective cerebral perfusion, still needs to be elucidated.

METHODS: In a period between April 2002 and March 2003, 22 patients (19 male, 3 female, with a mean age of 46.8 ± 12; range: 26 to 70 years old), underwent aortic arch repair using right brachial artery low flow (8 to 10 mL · kg–1 · min–1) selective antegrade cerebral perfusion under moderate hypothermia (26°C). There were 6 Stanford type-A dissections and 16 ascending aortic aneurysms. All patients were evaluated preoperatively and postoperatively (at seventh day and second month) for neurocognitive functions.

RESULTS: There was no operative mortality. The average cardiopulmonary bypass time was 115.0 ± 24.2 minutes and the average antegrade cerebral perfusion time was 29.8 ± 7.1 minutes (19 to 38 minutes). No major neurologic deficit was observed in the postoperative period. In terms of neurocognitive test results, between the preoperative and postoperative assessments for both hemispheric cognitive functions no deterioration was detected.

CONCLUSIONS: The low-flow selective antegrade cerebral perfusion technique through the right brachial artery may safely be used for the great majority of patients undergoing aortic arch repair without causing deteriorations in neurocognitive functions.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 Acknowledgments
 References
 
Neurocognitive dysfunction after open-heart surgery has a grave social and economical impact. In addition to the serious deterioration in the life quality, it prolongs in-hospital stay and causes a waste of resources [1]. Deep hypothermia and total circulatory arrest adds more risk to that of extracorporeal circulation. Recently, the use of selective antegrade cerebral perfusion is gaining popularity in the repair of aortic arch aneurysm or dissections [2–4]. Our group adopted a selective antegrade cerebral perfusion technique through right brachial artery, in conjunction with moderate hypothermia (26°C). This technique is simple, and eliminates the need of deep levels of hypothermia, shortens CPB and total operation times, allows for a reasonable time period in which an optimal repair can be undertaken without a frantic struggle. In addition, it has been reported to be as safe as other techniques in terms of clinical neurologic outcome after arch repairs [4]. There are reports to point out the safety of antegrade cerebral perfusion technique in reducing major neurologic event rate, but its value in decreasing neurocognitive impairment incidence is not thoroughly studied.

The aim of this study was to compare preoperative and postoperative neurocognitive functions in patients undergoing aortic arch repair by right brachial artery perfusion.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 Acknowledgments
 References
 
Demographics
Between April 2002 and March 2003, 43 patients underwent aortic arch repair using selective cerebral perfusion through right brachial artery perfusion at cardiovascular surgery clinic of Türkiye Yüksek Ihtisas Hospital. Among these, 21 could not complete preoperative neurocognitive testing due to low educational background or emergency nature of the operation. The remaining 22 patients, 19 male and 3 female, completed the preoperative evaluation and entered the study. The average age was 46.8 ± 12.2 years (range 26 to 70 years old). There were 6 patients with Stanford type-A aortic dissection (one being acute dissection) and 16 ascending aortic aneurysm extending over the proximal aortic arch. Demographics and operative data are presented in Table 1. Institutional ethic committee approval and informed patient consent was obtained from all patients.


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  		Table 1. Demographics and Operative Data

 
Operative technique
Our operative technique has been described in detail previously [4]. Briefly, dissection and cannulation of the right upper brachial artery was done before median sternotomy. A medial longitudinal incision is made along the bicipital groove into the axillary fossa. The incision follows the medial border of the biceps along its groove, which separates the biceps anteriorly from the triceps posteriorly. An incision 6- to 8-cm long is adequate for exposure of artery. The skin incision should be made anterior to the basilic vein. The incision is carried down to the fascia of the biceps after identifying its medial border. The muscle is then retracted anteriorly; the neurovascular bundle appears under a thin aponeurotic sheath, which is then opened. The median nerve is exposed, mobilized laterally, thus exposing the artery. After heparin administration, arterial soft clamps are placed proximal and distal to the cannulation site. Transverse arteriotomy is made by scalpel. The artery is cannulated with a nonwire-reinforced venous return catheter (California Medical Laboratories, Irvine, CA), the tip of which is trimmed to 16 to 18 F diameters according to the size of patient's brachial artery. The catheter is gently inserted into the artery, as its tip is positioned 5- to 7-cm proximal to the arteriotomy. The cannula is then connected to the CPB circuit as usual for any arterial return cannula.

Following full-length median sternotomy, venous cannulation is done using a two-stage single venous cannula. Cardiac arrest is established by cold crystalloid antegrade/retrograde cardioplegia. Intermittent retrograde cold blood cardioplegia with terminal warm blood cardioplegia is used for myocardial protection along with topical ice-cold saline irrigation. Cardiopulmonary bypass is instituted at a rate of 2.0 to 2.2 L · min–1 · m–2. Flow rates above 4.5 L/min are generally avoided even in patients having large body surface area (BSA) to prevent high-pressure gradients along the arterial cannulation site. The largest BSA in this cohort was 2.25 m2 (Table 1). The flow is decreased to 500 to 600 mL/min (8 to 10 mL · kg–1 · min–1) at 26°C rectal temperature.

The innominate, left common carotid, and, occasionally, the left subclavian artery (but only if the returning blood interferes with suturing) are clamped with soft vascular clamps. Cross-clamp on the aorta is released. All arch reconstructions and distal anastomosis were performed with open aortic anastomosis technique while low-flow perfusion through the brachial artery continued. Because all ascending aneurysms of this cohort were reaching the origin of innominate artery and applying the cross clamp proximal to the innominate artery would influence the security of the distal anastomosis, open distal anastomosis technique was the preferred method for ascending aneurysms. After terminating the distal repair the flow through the upper brachial artery cannula is increased gradually as the soft clamps on the brachiocephalic vessels are released. Air is removed from the vessels and grafts, which are then filled with blood, and the distal graft is cross clamped. Normal flow rate is reached through the brachial artery cannula and rewarming is begun in accordance with the time necessary for proximal repair. Table 2 outlines the surgical procedures used for the repair in this series.


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  		Table 2. Operative Technique

 
Neuropsychological testing
Each patient was evaluated with a comprehensive neuropsychological examination administered by the same psychologist (H.T.) 1 day before the operation (T1), at the seventh postoperative day (T2), and at second postoperative month (T3). The examination consisted of five different tests, which are described below.

Hospital anxiety and depression scale
Because a patient undergoing any open-heart procedure is a major cause of anxiety, a hospital anxiety and depression scale (HADS) was applied to all patients before evaluation for the purpose of measuring the affect of anxiety and depression on the subsequent neurocognitive test [5].

Raven's standard progressive matrices test
Raven's standard progressive matrices (RSPM) test was designed to measure a person's ability to establish a perceptual relation and to reason by an analogy independent of language or formal schooling. This has been reported to be sensitive particularly in the injuries involving the right cerebral hemisphere and parietal lobe [6].

Line orientation test
The line orientation test (LOT) measures visual-perceptual/visual-spatial discrimination, and the patient's ability to analyze and synthesize of visual form and spatial relations. This test is sensitive for the right hemisphere and the right parietal lobe injuries in special [7].

Stroop task
The Stroop task (ST) is a test of mental vitality and flexibility. It measures the divided attention and response inhibition. The test uses our ability to read words more quickly and automatically than to name colors. This simple examination evaluates the attention, mental speed, and mental control. It is more specific for dominant frontal lobe functions [8, 9].

Rey auditory verbal learning test
This test examines processes involved in learning and verbal memory. Rey auditory verbal learning test (RVALT) allows the measurement of several indices of learning and memory that reflect underlying component processes, such as acquisition rate and retrieval efficiency. This test evaluates verbal learning, immediate and delayed recall, retention, distraction and recognition memory and is sensitive for hippocampus and left temporal lobe injuries [10].

Statistical analysis
Measured values are given as mean ± standard deviation. Statistical analysis was performed using SPSS for Windows statistical program (version 10; SPSS, Inc, Chicago, IL). Results of tests were compared by analysis of variance (ANOVA) with repeated measurements in parametric variables and Friedman test for nonparametric variables. If a significant difference was detected (p < 0.05), then pairwise comparison between the time periods made by post hoc multiple comparison test.


   Results
Top
 Abstract
 Introduction
 Material and methods
 Results
Comment
 Acknowledgments
 References
 
There was no operative mortality or major neurologic complication in this series of 22 patients.

HADS test results
In order to prevent the effects of anxiety and depression, HADS test was administered to all patients before applying neurocognitive tests. Although depression levels were decreased postoperatively there were no statistically significant difference when compared with preoperative levels (p = 0.256). However, patient anxiety was found significantly decreased at the postoperative evaluation in comparison to the preoperative records (p = 0.004; Table 3).


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  		Table 3. Preoperative and Postoperative Neurocognitive Test Scores for Right Hemisphere

 
RSPM and LOT tests
These are more specific for the right hemispheric cognitive functions, and did not differ between the three time evaluations (RSPM total p = 0.861; RSPM time p = 0.314; LOT p = 0.256; Table 3).

RAVLT and ST tests
These tests are primarily used for the left hemispheric cognitive functions and three subsets of ST tests (III, IV, and V) revealed significant improvement at the postoperative second month (T3) in comparison to the preoperative records (p = 0.001, p = 0.014, p = 0.031, respectively). Similarly, in the three subsets of RAVLT evaluation, namely total verbal learning, immediate recall, and recognition, significant improvement was detected both at the first postoperative week (T2) and the second postoperative month (T3) in comparison to the preoperative results (p = 0.004, p = 0.000, and p = 0.000, respectively). The remaining subsets of RAVLT measurements (distraction trial, retention, and delayed recall) also revealed a similar improvement at the second postoperative month (T3; p = 0.038, p = 0.05, and p = 0.034, respectively), but not at the first postoperative week (T2; Table 4).


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  		Table 4. Preoperative and Postoperative Neurocognitive Test Scores for Right Hemisphere

 

   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
Acknowledgments
 References
 
Although neurocognitive function impairment after open heart operations is a well-documented phenomenon [11], reported severity and type of cognitive dysfunction considerably vary between the studies, depending on the methodology, study population characteristics, selected criteria for neurocognitive impairment, and the time points of postoperative assessment [12]. There are many references to some degree of decline in cognitive functions early after CABG in a significant proportion of patients [13]. The incidence of cognitive regression ranges from 3% to 50% of patients, depending on the type of patient, definition of the function loss, and timing of neuropsychological assessment [13]. A pooled analysis of six comparable studies yielded a proportion of 23% of patients with cognitive decline 2 months after the operation [14].

Cerebral morbidity after CABG has largely been attributed to the use of cardiopulmonary bypass [15], however the cause of cerebral injury after CPB is probably multifactorial. It has been demonstrated that neuropsychological decline correlates with the sum of microembolic load during extracorporeal circulation [16]. Furthermore, a significant reduction in both microembolism rate and neuropsychological decline has been demonstrated by the use of filters in the CPB circuit [17]. All these imply that microembolism may be an important source of subtle cerebral injury after CPB. On the other hand, with the advances in extracorporeal circulation technology and manufacturing, recent studies fail to detect significant neurocognitive function decline following open-heart surgery. Westaby and colleagues [18], as many others [19, 20], report similar incidence of neuropsychological dysfunction after coronary surgery with and without CPB. Annemieke and coworkers [21] did not find an increase in self-reported cognitive failures in CABG patients 1 year after operation. Moreover, no difference was reported by means of cognitive failure between patients undergoing on-pump and off-pump CABG. In contrast, the rate of self-reported cognitive failures in healthy controls was found to be higher than that in the CABG patients. These findings suggest that CABG itself does not yield personally experienced cognitive decline 1 year after in a substantial patient proportion, irrespective of the type of surgical technique (on-pump or off-pump). Selnes' observations [22] indicate that the changes in neuropsychological test scores from baseline to follow-up are very similar for surgical and nonsurgical control patients. There is little or no evidence to a change between the two groups, by means of average scores, standard deviations, or shape of the distributions. These data suggest that early postoperative cognitive changes after CABG may be transient and reversible by 3 months.

Aortic arch repairs, on the other hand, necessitate the exclusion of the arch from circulation, therefore possesses additional risk for major neurologic complication in this context. Many techniques and approaches have been constantly tried in an attempt to overcome the serious consequences of the interruption of arch-derived blood flow to the brain during the repair. Among these are, deep hypothermia/total circulatory arrest, retrograde brain perfusion and many variations of antegrade brain perfusion techniques. Svensson and coworkers [23] have observed no difference in terms of neurocognitive functions between these three approaches during aortic arch operations.

There are many variations of antegrade perfusion techniques. Frist and associates [24] described a technique involving unilateral low-flow brain perfusion by either innominate or left carotid artery. Our group has modified this technique by switching the cannulation site to the right brachial artery. The main advantage of this technique is its safety and simplicity. Besides, the untoward effects of deep hypothermia on the entire organism are avoided [4].

Recent studies report low incidences of major neurologic complications with the use of antegrade cerebral perfusion in aortic repairs, but data referring to the effects on neurocognitive disorders is limited. According to Svensson and colleagues [23], antegrade brain perfusion possesses no additive protective effect in aortic arch repairs. They also report that a blinded neuropsychologist's clinical evaluation of the patient-based neurocognitive testing, then diagnosis of a new deficit on this base line is the proper method for determining the neurocognitive deficits [23].

The above-mentioned study was mainly focused on the comparison of results of different protective methods postoperatively. Our study was designed to make preoperative and postoperative comparison of antegrade cerebral perfusion techniques on neurocognitive functions of right and left hemisphere.

We detect no postoperative decline in any neurocognitive test. For example, AVLT, being specific to left temporal lobe injuries, and ST, being specific to frontal and especially dominant frontal lobe injuries, did not reveal any deterioration after the procedure. On the contrary, we observed significant improvements as indicated by some tests. In these instances, we thought that preoperative anxiety, which is expected to be considerable, might be responsible for the low preoperative scores and subsequent appearance of some postoperative improvement. Nevertheless, it should be emphasized that we have not observed any deterioration on neurocognitive testing in patients undergoing aortic arch repair by antegrade selective perfusion.

The concept of unilateral selective cerebral perfusion may arise concern about the adequacy of preservation for contra lateral hemisphere. Hypothetically the absence of one of the three communicating arteries in the circle of Willis should not carry hypoperfusion risk because the blood from the right brachial artery will perfuse the whole brain through vertebral, basilar, and internal carotid arteries. The only case in which a potential hazard for contralateral lobe hypoperfusion exists is the absence of both anterior and left posterior communicating arteries. This combination should be very rare as there is no specific reference to it in the literature. However, even in this case, only the frontal and temporal parts should become affected [25]. Di Eusanio and coworkers [26], who use antegrade perfusion in arch repairs, advise Doppler ultrasonography, digital substraction angiography, and transcranial Doppler ultrasonography of the extracranial and intracranial vessels, for the preoperative evaluation of the cerebral circulation. In our experience, visual confirmation of the returning blood through left common carotid and subclavian arteries during antegrade perfusion is a valuable indicator for contra lateral hemispheric perfusion. In all cases, the amount of this returning blood was observed to be satisfactory.

A major limitation of the presented study is the small s ample size, partly due to the exclusion of the emergency cases and the patients of low educational levels having difficulty to perform neurocognitive tests.

In conclusion, the technique of low flow antegrade selective cerebral perfusion through the right brachial artery is safe in protecting neurocognitive functions. This technique may be safely used for a vast majority of aortic aneurysm and dissection cases requiring arch repair or open distal anastomosis.


   Acknowledgments
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 Acknowledgments
References
 
The authors would like to thank Hatice Kafadar (Hacettepe University, Department of Psychology) for taking part in the administration of the neuropsychological tests, Professor Sureyya Dikmen (University of Washington, Department of Rehabilitation Medicine) for advising on the neurocognitive test scoring, and Dr Ali Demirbag (epidemiological and statistical editor of the Turkish Journal of Gastroenterology), for his help in statistical analysis of the retrieved data.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 Acknowledgments
 References
 

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