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Ann Thorac Surg 2007;83:S796-S798
© 2007 The Society of Thoracic Surgeons

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Supplement

Aortic Arch Replacement Using Selective Cerebral Perfusion

First Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan

Accepted for publication October 17, 2006.

^_* Address correspondence to Dr Kazui, First Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu431-3192, Japan. (Email: tkazui{at}hama-med.ac.jp).

Presented at Aortic Surgery Symposium X, New York, NY, April 27–28, 2006.

	Abstract

Top Abstract Introduction Material and Methods Results Comment References

 
BACKGROUND: The present study was conducted to report our clinical experience with aortic arch replacement using selective cerebral perfusion (SCP) and determine the independent predictors of in-hospital mortality and neurologic outcome.

METHODS: We studied 472 consecutive patients who underwent aortic arch replacement using SCP between January 1986 and February 2006. All operations were performed with the aid of hypothermic extracorporeal circulation, SCP, and in most cases, systemic circulatory arrest for open distal anastomosis. The etiology of aortic diseases included acute aortic dissection in 126 patients (27%), chronic aortic dissection in 102 (21%), and degenerative aneurysm in 245 (52%). Total arch replacement was performed in 420 patients (89%). Mean SCP time was 88 ± 32 minutes.

RESULTS: The overall in-hospital mortality was 9.3%, but it dropped significantly to 4.1% in the most recent 266 patients. Independent predictors of in-hospital mortality were early series, renal/mesenteric ischemia, pump time, increasing age, chronic renal dysfunction, history of cerebrovascular accident (CVA), and previous ascending or arch operation. Overall postoperative temporary and permanent neurologic dysfunction were 4.7% and 3.2%, respectively. A history of CVA was the only predictor of temporary neurologic dysfunction, whereas CVA and pump time were independent predictors of permanent neurologic dysfunction. SCP time had no significant correlation with in-hospital mortality and neurologic outcome.

CONCLUSIONS: SCP facilitates complicated aortic arch replacement, resulting in a reduction of mortality and morbidity for arch aneurysms or dissections.

	Introduction

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It is essential to select optimal strategies for cerebral protection and surgical technique of arch repair to improve the surgical outcome of arch aneurysms or dissections. Antegrade selective cerebral perfusion (SCP) has been the cerebral protection method of choice at our institution if the required cerebral protection time will exceed 30 minutes [1–4].

The aim of the present study was to report the clinical experience with SCP during aortic arch replacement and to determine the independent predictors of in-hospital mortality and neurologic outcome.

	Material and Methods

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This was a retrospective study in which individual patient data were not revealed. For this type of study, individual patient consent and institutional approval are waived.

Between January 1986 and February 2006, 589 patients were operated on for arch aneurysm or dissection using hypothermic cardiopulmonary bypass (CPB), and deep hypothermic circulatory arrest (DHCA), with or without retrograde cerebral perfusion (RCP) or antegrade SCP. Included in this study are 472 patients (79%) who received the operation with the aid of SCP. Their mean age was 64 ± 13 years (range, 18 to 92 years), and 65% were men. A total of 126 patients (27%) were treated for acute dissection, 102 (21%) for chronic dissection, and 245 (52%) for degenerative and atherosclerotic aneurysm. Emergent operations were performed on 138 patients (29%) within 24 hours of admission for rupture of their aneurysm or acute dissection.

Preoperative complications included shock in 40 patients (8.5%), chronic obstructive pulmonary disease in 44 (9.3%), a history of cerebrovascular accident in 70 (14.8%), coronary artery disease in 68 (14.4%), and chronic renal dysfunction in 49 (10.4%), with 12 (2.5%) requiring hemodialysis. Aortic dissection–related complications included cardiac tamponade in 52 (11.0%), myocardial ischemia in 10 (2.1%), cerebral ischemia in 13 (2.8%), renal/mesenteric ischemia in 12 (2.5%), and leg ischemia in 17 (3.6%). Eighty patients (17%) had undergone previous cardiovascular procedures.

In all elective cases, preoperative cerebral four-vessel (bilateral internal carotid and vertebral artery) angiography, cerebral computed tomographic scanning, or magnetic resonance imaging were performed to rule out cerebrovascular disease and to select the site of cerebral perfusion.

Operations were performed through a median sternotomy in 446 patients (94%) and through median sternotomy with opening of the left pleura in 13 (3%). A left anterior thoracotomy was used in 13 (3%) for an extended descending aortic replacement. The site of arterial cannulation for CPB in most of the recent cases was the ascending aorta, and the right axillary artery was used when necessary.

The details of hypothermic CPB and antegrade SCP have been described previously [1, 3]. Briefly, systemic circulation is arrested when the patient is cooled by extracorporeal circulation to a rectal temperature of 25°C (usually dropping later to 22°C). Both innominate and left common carotid arteries are cannulated and are perfused at a rate of 10 mL/(kg · min) by a single pump. The left subclavian artery is kept cross-clamped during SCP, except in cases where an additional left subclavian artery perfusion is performed: (1) occlusion of the right vertebral artery, (2) lack of efficient intracranial arterial communication, or (3) dominant left vertebral artery. The right radial arterial pressure and bilateral catheter tip pressure are adjusted to about 40 mm Hg to regulate perfusion pressure. During CPB, arterial blood pH is managed according to the -stat strategy.

More recently, unilateral cerebral perfusion through the right axillary artery instead of bilateral cerebral perfusion has been used in selected patients undergoing hemiarch replacement for acute type-A aortic dissection. CPB is instituted through the right axillary artery. After cooling to a rectal temperature of 20°C, both innominate and left common carotid arteries are cross-clamped at their origins, and systemic circulatory arrest is induced. Then, unilateral cerebral perfusion through the right axillary artery is maintained at a flow rate of 5 to 10 mL/(kg · min). The number of arch vessels used for SCP in our series was a single vessel in 24 patients (5%), two vessels in 438 (93%), and three vessels in 10 (2%).

Real-time intraoperative monitoring of SCP includes perfusion pressure and flow rates, two-channel serial electroencephalography, and two-channel near-infrared spectroscopy. If available, internal jugular venous oxygen saturation and transcranial Doppler sonography are also used.

Open distal anastomosis has been used in 98% of patients since March 1987. 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 was performed in the remaining 469 (99%). Ascending aortic replacement (AAR) and hemiarch replacement (HAR) were performed in 49 patients (10%); AAR and total arch replacement (TAR) in 225 patients (48%); AAR, TAR, and descending aortic replacement (DAR) in 168 (35%); isolated TAR in 19 patients (4%), and TAR and DAR in 8 patients (2%). Overall, TAR was performed in 420 patients (89%). TAR with a concomitant elephant trunk technique was performed in 63 patients (13%).

	Results

Top Abstract Introduction Material and Methods Results Comment References

 
The overall in-hospital mortality was 9.3% (44/472). In-hospital mortality was 16.0% in the early series (1986 to 1996) of 206 patients and 4.1% (n = 11) in the 266 patients in the late series (1997 to 2006; p < 0.001), even with the inclusion of emergent cases. Table 2 summarizes the independent predictors of in-hospital death as estimated by multivariable step-wise logistic regression analysis. It revealed that early series, renal/mesenteric ischemia owing to acute dissection, pump time, increasing age, chronic renal dysfunction, history of CVA, and previous ascending/arch operation were significant independent predictors of in-hospital mortality.

Mean SCP time was 88.2 ± 32.2 minutes. There was no significant correlation between SCP time and in-hospital mortality or neurologic outcome.

	Comment

Top Abstract Introduction Material and Methods Results Comment References

 
Cerebral protection methods currently used are DHCA with or without RCP, and antegrade SCP. Several experimental and clinical studies indicate that antegrade SCP presents several advantages compared with DHCA with or without RCP. Antegrade SCP can extend the safe duration of circulatory arrest up to 90 minutes [5], allowing meticulous aortic arch repair and facilitating the complex and time-consuming TAR. SCP obviates the need for deep hypothermia, thus reducing pump time and the risk of hypothermia-related complications such as pulmonary insufficiency and coagulopathy. SCP is more effective in supplying oxygenated blood to the brain, thus ensuring a more physiologic brain energy metabolism. SCP is therefore considered to be the most reliable method of preventing ischemic injury to the brain.

A suggested major drawback of SCP is the risk of cerebral embolism or malperfusion while cannulating the arch vessels. But complications related to arch vessel cannulation can be completely avoided by transecting each arch vessel 1 cm distal to its origin, where it is free from atheroma or dissection, and by cannulating it through the arteriectomy under direct vision.

In our series, the sites of arch vessel cannulation for SCP were the innominate or right axillary artery and the left common carotid artery. In principle, however, selection of cannulation sites is determined by the pathophysiology of the intracerebral and extracerebral arterial system as well as the expected duration of cerebral protection, which is related to the underlying disease and the extent of aortic replacement. Using this integrated cerebral protection method of SCP with systemic circulatory arrest, we were able to perform TAR in a more aggressive manner to include even the acute aortic dissection cases and to extend aortic replacement down to the mid-descending aorta through a median sternotomy alone.

We prefer the separated graft TAR technique to the en bloc technique because it presents 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 anastomoses can be performed at the intact distal sites of the arch vessel where dissection has not extended;

3 the pathologic portion of the aortic arch can be completely resected in Marfan patients; and

4 bleeding from the site of the arch vessel anastomoses can be controlled easily.

The average SCP time was 88 minutes in the present series, and it had no significant correlation with in-hospital mortality or neurologic outcome.

In summary, with the refined use of antegrade SCP and the separated graft technique, we could substantially reduce in-hospital mortality and neurologic complications in recent patients with arch aneurysm or dissection.

	References

Top Abstract Introduction Material and Methods Results Comment References

 

1. Kazui T, Washiyama N, Bashar AHM, et al. Total arch replacement using aortic arch branched grafts with the aid of antegrade selective cerebral perfusion Ann Thorac Surg 2000;70:3-9.[Abstract/Free Full Text]
2. Kazui T, Washiyama N, Bashar AHM, et al. Extended total arch replacement for acute type A aortic dissection: experience with seventy patients J Thorac Cardiovasc Surg 2000;119:558-565.[Abstract/Free Full Text]
3. Kazui T, Washiyama N, Bashar AHM, Terada H, Yamashita K, Takinami M. Improved results of atherosclerotic arch aneurysm operations with a refined technique J Thorac Cardiovasc Surg 2001;121:491-499.[Abstract/Free Full Text]
4. Kazui T, Yamashita K, Washiyama N, et al. Usefulness of antegrade selective cerebral perfusion during aortic arch operations Ann Thorac Surg 2002;74:S1806-S1809.[Abstract/Free Full Text]
5. Sakurada T, Kazui T, Tanaka H, Komatsu S. Comparative experimental study of cerebral protection during aortic arch reconstruction Ann Thorac Surg 1996;61:1348-1354.[Abstract/Free Full Text]

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