ATS
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

Ann Thorac Surg 2008;85:624-627. doi:10.1016/j.athoracsur.2007.06.037
© 2008 The Society of Thoracic Surgeons
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Ruggero De Paulis
Andrea Salica
Daniele Maselli
Raffaele Scaffa
Alessandro Bellisario
Luca Weltert
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by De Paulis, R.
Right arrow Articles by Weltert, L.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by De Paulis, R.
Right arrow Articles by Weltert, L.
Related Collections
Right arrow Great vessels

New Technology

Initial Experience of an Arterial Shunt for Bilateral Antegrade Cerebral Perfusion During Hypothermic Circulatory Arrest

Ruggero De Paulis, MD*, Andrea Salica, MD, Daniele Maselli, MD, Raffaele Scaffa, MD, Alessandro Bellisario, MD, Luca Weltert, MD

Cardiac Surgery Department, European Hospital, Rome, Italy

Accepted for publication June 13, 2007.

* Address correspondence to Dr De Paulis, Cardiac Surgery Department, European Hospital Via Portuense 700, Rome, 00149, Italy (Email: depauli{at}tin.it).


   Abstract
Top
 Abstract
Introduction
 Technology
 Technique
 Comment
 Disclosures and Freedom of...
 Footnotes
 References
 
Purpose: The purpose of this study is to describe an intravessel cerebral shunt that allows perfusion of both cerebral hemispheres through the axillary artery.

Description: The cerebral shunt is a 10-cm to 12-cm long cannula with a lumen for blood perfusion and two balloons, one at each distal end. The proximal ballon is adapted for retaining the proximal end of the catheter in the innominate artery; the second inflatable balloon is adapted for retaining the distal end of the catheter into the left common carotid artery.

Evaluation: Three consecutive patients received bilateral brain perfusion through the right axillary artery with the use of this cerebral shunt.

Conclusions: The cerebral shunt allowed bilateral cerebral perfusion as verified with cerebral oxymetry in the absence of any evident neurologic dysfunction.


   Introduction
Top
 Abstract
 Introduction
Technology
 Technique
 Comment
 Disclosures and Freedom of...
 Footnotes
 References
 
Aortic arch surgery carries an intrinsic risk of neurologic damage related to the suspension of physiologic blood flow into the epiaortic vessels. If a right subclavian or axillary artery is used for systemic blood return, unilateral antegrade cerebral perfusion can be carried out by occluding the innominate artery, thus perfusing the brain through the right carotid and right vertebral arteries; the surgical field is free of cannulae and the surgical procedure is facilitated [1] (Fig 1). However, given the wide anatomical and functional variations in the circle of Willis, regional ischemia in the left side of the brain might occur in some patients. A concomitant selective perfusion of the left common carotid artery seems to be safer even if it can impair exposure and handling of the aortic arch branches [2] (Fig 2). We report our experience with a cerebral shunt that can be used in concomitance with right axillary artery cannulation to connect the innominate artery and the left common carotid artery to achieve bilateral brain perfusion while leaving an unobstructed operative field.


Figure 1
View larger version (117K):
[in this window]
[in a new window]

  		Fig 1. Diagram representing the standard setup of unilateral antegrade cerebral perfusion for those patients receiving systemic perfusion through the right subclavian or axillary artery. During the period of circulatory arrest, antegrade selective unilateral brain perfusion is obtained by simply occluding the innominate artery. (Arrows indicate direction of blood flow.)

 

Figure 2
View larger version (113K):
[in this window]
[in a new window]

  		Fig 2. Diagram representing the standard setup of antegrade cerebral perfusion for those patients receiving systemic perfusion through the right subclavian or axillary artery. During the period of circulatory arrest, antegrade selective bilateral brain perfusion is obtained by occluding the innominate artery and selectively perfusing the left carotid artery by means of an inflatable balloon catheter. (Arrows indicate direction of blood flow.)

 
Between April 2006 and December 2006, 3 adult patients with chronic isolated aneurysm involving the ascending aorta from the sinotubular junction to the aortic arch underwent surgery at the European Hospital of Rome, Italy. Primary indication for surgery was a maximum aortic diameter exceeding 5.0 cm. Patients characteristics and intraoperative data are reported in Table 1.


View this table:
[in this window]
[in a new window]

  		Table 1 Patient Characteristics
 
Clinical endpoints were both the evaluation of brain perfusion during surgical procedure and neurologic outcome. Feasibility endpoints were based on surgical comfort of the device.

Brain perfusion was evaluated by transcranial optical spectroscopy (Invos System, Somanetics, Troy, MI). This was obtained by applying detectors on the skin of the frontal region. Data were obtained separately and continuously from both hemispheres during the whole procedure from anesthesia induction until closure of the chest. Data from both hemispheres were compared to verify any differences in brain oximetry during selective antegrade perfusion.

All patients gave informed consent to participate in this study that was approved by the ethical committee of our institution.


   Technology
Top
 Abstract
 Introduction
 Technology
Technique
 Comment
 Disclosures and Freedom of...
 Footnotes
 References
 
Device Description
The cerebral perfusion cannula or shunt (Med-Europe [San Pietro Casale, Italy]) is used to connect the ostium of the innominate artery with the left common carotid artery to obtain a bilateral cerebral antegrade perfusion when the right subclavian or right axillary artery is used for arterial return.

The cannula is 10-cm to 12-cm long with a diameter of 12-French and is provided with a lumen for blood perfusion; an inflatable balloon at the proximal end, which is adapted for retaining the proximal end of the catheter in the innominate artery; and a second inflatable balloon, which is adapted for retaining the distal end of the catheter into the left common carotid artery (Fig 3). The nominal in vitro flow within a pressure range of 60 mm Hg to 80 mm Hg ranges from 1.5 L to 2 L of water.


Figure 3
View larger version (80K):
[in this window]
[in a new window]

  		Fig 3. The cerebral shunt as described in the text was used to connect the innominate artery with the left carotid artery. The inflow tip has a flat-shaped orifice to optimize the blood inflow, whereas the distal tip is bevelled to facilitate insertion into the left carotid artery.

 
The catheter tube includes inflation lumens extending longitudinally through the catheter tube. The inflation lumens are in fluid communication with the proximal and distal balloons and are provided with a connector for a syringe to inflate the balloons. One lumen outlet is adjacent to the proximal end of the catheter, whereas the other lumen outlet is adjacent the distal end of the catheter. In this way, once the catheter is in place and the antegrade cerebral perfusion is started, perfusion pressure of both carotid arteries can easily be monitored through the right radial artery only.


   Technique
Top
 Abstract
 Introduction
 Technology
 Technique
Comment
 Disclosures and Freedom of...
 Footnotes
 References
 
Surgical Procedures and Results
All surgical procedures were performed by full median sternotomy. After exposing the right axillary artery, an 8-mm Dacron graft was anastomosed end-to-side to the artery itself by a running suture of 5-0 polypropylene and was cannulated for arterial return. Venous drainage was obtained by atriocaval cannulation. All procedures were performed under moderate hypothermic circulatory arrest; the open aorta technique was chosen to perform distal anastomoses.

Esophageal and rectal temperatures were monitored and extracorporeal circulation was interrupted at 24°C of rectal temperature. During the cooling period, the epiaortic trunks were isolated and snaring tourniquets were positioned. The ascending aorta was opened and the ostia of the epiaortic trunks were exposed. The inflow tip of the cerebral shunt was gently introduced into the innominate artery, the inflow ballon was inflated, the artery was snared, and the cannula was washed out with blood coming from the pump. Then, the outflow tip was gently introduced into the left carotid artery, the distal balloon was inflated, and the left carotid artery was snared to prevent slippage (Fig 4).


Figure 4
View larger version (111K):
[in this window]
[in a new window]

  		Fig 4. Diagram representing the setup of antegrade cerebral perfusion using the cerebral shunt here described. During the period of circulatory arrest, antegrade selective bilateral brain perfusion is obtained by using the cannula to connect the innominate artery and the left carotid artery. In this way, bilateral brain perfusion can be obtained through the right subclavian or axillary artery with minimal obstruction of the operative field. (Arrows indicate direction of blood flow.)

 
Antegrade bilateral cerebral perfusion with isothermic blood was started through the right axillary artery at a flow of 10 to 15 mL/kg/min according to perfusion pressure. Distal anatomosis was performed by 4-0 polypropylene running suture. Just before completion of the distal anastomosis the cerebral cannula was removed and drawn out from the lumen of the vascular graft. Cardiopulmonary bypass was then resumed and the patient was re-warmed. In all cases, proximal anastomosis was performed during the re-warming phase.

None of the patients died or showed major or minor neurologic events. Mean perfusion time was 15 minutes and there were no difference in the cerebral oxymetry of the two hemispheres that was within the normal range through the procedure (Table 2). All patients were discharged within 7 days of surgery.


View this table:
[in this window]
[in a new window]

  		Table 2 Cerebral Oxymetry by Transcranial Optical Spectroscopy During the Procedure
 

   Comment
Top
 Abstract
 Introduction
 Technology
 Technique
 Comment
Disclosures and Freedom of...
 Footnotes
 References
 
In the last decade, two main issues contributed to improved hospital mortality and morbidity in patients undergoing aortic arch surgery: (1) the implementation of new methods of cerebral protection and (2) the reduction of brain embolic risk by means of alternative arterial cannulation sites for cardiopulmonary bypass.

To guarantee cerebral protection, several options have been developed in time: (1) deep hypothermic circulatory arrest, (2) retrograde cerebral perfusion, and (3) selective antegrade cerebral perfusion.

Hypothermic circulatory arrest at a temperature of 18°C offers a relatively safe period of 30 minutes to perform the procedure and a clear operative field, but risk of minor cerebral damage is always present. Duration of hypothermic circulatory arrest exceeding 25 minutes has been associated with temporary neurologic dysfunction, with permanent neurologic deficit or death [3, 4]. Furthermore, metabolic studies confirmed that the safe duration of hypothermic circulatory arrest may be limited to 30 minutes [5].

The idea to supply the brain with blood from the venous side to deliver nutrients while at the same time flushing out air and debris led a number of surgical teams to adopt cold retrograde cerebral perfusion through the superior vena cava [6]. However, further studies have demonstrated that very little capillary flow was provided with retrograde cerebral perfusion [7], with the major benefit being limited only to the continuous cooling of the brain.

Finally, selective antegrade cerebral perfusion of the cerebral vessels has been adopted because it directly supplies nutrients and oxygen to the brain allowing a longer period of "safe" circulatory arrest [8]. Although there is some evidence that unilateral brain perfusion through a single carotid artery might achieve total brain perfusion in the presence of a normal circle of Willis [1], the safest method of brain protection is better achieved through perfusion of both carotid arteries [2]. This is even more important when a long, complex and time-consuming aortic arch surgery is planned. Selective antegrade perfusion is usually achieved through direct cannulation of both carotid arteries. However, as a small drawback of this technique, they might somehow encumber the operating field.

Regarding the site of cannulation, the common femoral artery is the most commonly used site for arterial inflow; however, this route is often unavailable because of severe ileo-femoral disease, which can expose it to the risk of retrograde atheroembolism from an atherosclerotic aorta. To overcome these problems the axillary and innominate artery have gained popularity in the last few years as an alternative inflow site. Furthermore, the axillary artery can also be used for selective perfusion of the right carotid artery once circulatory arrest begins. Bilateral brain perfusion is therefore obtained by direct cannulation of the left carotid artery.

With the aim of obtaining an empty operative field, while at the same time perfusing both carotid arteries, the simple arterial shunt herein described was developed. Once in place it allowed a complete brain perfusion. Cannula flexibility allowed a good handling; cannula positioning required in all instances less than 1 minute and the curved configuration inside the aortic arch (Fig 4) allowed a nonobstructed access to the operative field.

Axillary cannulation coupled with bilateral selective brain perfusion through the cerebral shunt as previously described seems to offer an efficient and simultaneously elegant and practical way to protect the brain. The cannula retains all advantages of antegrade selective bilateral perfusion of the brain while avoiding the drawbacks of having a complex setup and a cluttered surgical field.

Further studies are warranted to test the safety and efficacy of this type of bilateral cerebral perfusion through the axillary artery in a larger series of patients with a longer period of perfusion time.

Study Limitations
Given the short period of antegrade cerebral perfusion, these results do not attempt to prove that the surgical approach previously described is sufficient to prevent any neurologic damage. Our purpose was just to demonstrate the feasibility of perfusing both carotid arteries through a single arterial inflow. For this reason, comparative studies with and without the shunt were not performed.

Severely diseased or dissected or aneurysmal great vessels are not the ideal setting for every technique based on antegrade perfusion of the brain and obviously also for our shunt.

In case of total arch reconstruction with branched grafts, the shunt can be used to perfuse the left carotid artery while performing the anastomoses on the descending aorta and on the left subclavian artery. Perfusion of the left carotid is then stopped in the short period needed to perform the anastomosis with the respective branch of the graft and re-started through the side branch of the graft used to perfuse the lower body.


   Disclosures and Freedom of Investigation
Top
 Abstract
 Introduction
 Technology
 Technique
 Comment
 Disclosures and Freedom of...
Footnotes
 References
 
The clinical study for the evaluation of the arterial shunt for bilateral antegrade cerebral perfusion was not supported financially by Med-Europe. None of the authors have a financial agreement with Med-Europe. All the authors had full control of the design of the study, methods used, outcome measurements, analysis of the data, and production of the written report.


   Footnotes
Top
 Abstract
 Introduction
 Technology
 Technique
 Comment
 Disclosures and Freedom of...
 Footnotes
References
 
Disclaimer The Society of Thoracic Surgeons, the Southern Thoracic Surgical Association, and The Annals of Thoracic Surgery neither endorse nor discourage use of the new technology described in this article.


   References
Top
 Abstract
 Introduction
 Technology
 Technique
 Comment
 Disclosures and Freedom of...
 Footnotes
 References
 

  1. Panos A, Murith N, Bednarkiewicz M, Khatchatourov G. Axillary cerebral perfusion for arch surgery in acute type A dissection under moderate hypothermia Eur J Cardiothorac Surg 2006;29:1036-1039.[Abstract/Free Full Text]
  2. Olsson C, Thelin S. Antegrade cerebral perfusion with a simplified technique: unilateral versus bilateral perfusion Ann Thorac.Surg 2006;81:868-874.[Abstract/Free Full Text]
  3. Ergin MA, Galla JD, Lansman SL, Quintana C, Bodian C, Griepp RB. Hypothermic circulatory arrest in operations on the thoracic aorta: determinants of operative mortality and neurologic outcome J Thorac Cardiovasc Surg 1994;107:788-799.[Abstract/Free Full Text]
  4. Ergin MA, Uysal S, Reich DL, et al. Temporary neurological dysfunction after deep hypothermic circulatory arrest: a clinical marker of long-term functional deficit Ann Thorac Surg 1999;67:1887-1890.[Abstract/Free Full Text]
  5. McCullough JN, Zhang N, Reich DL, et al. Cerebral metabolic suppression during hypothermic circulatory arrest in humans Ann Thorac Surg 1999;67:1895-1899.[Abstract/Free Full Text]
  6. Bavaria JE, Pochettino A. Retrograde cerebral perfusion (RCP) in aortic arch surgery: efficacy and possible mechanisms of brain protection Semin Thorac Cardiovasc Surg 1997;9:222-232.[Medline]
  7. Boeckxstaens CJ, Flameng WJ. Retrograde cerebral perfusion does not perfuse the brain in nonhuman primates Ann Thorac Surg 1995;60:319-327.[Abstract/Free Full Text]
  8. Kazui T, Washiyama N, Muhammad BAH, 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]



This article has been cited by other articles:


Home page
 Eur. J. Cardiothorac. Surg.Home page
R. De Paulis, D. Maselli, R. Scaffa, and S. Nardella
Double-arterial cannulation for aortic valve replacement with porcelain aorta
Eur. J. Cardiothorac. Surg., October 1, 2009; 36(4): 769 - 770.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
P. Urbanski
Arterial Shunt for Bilateral Antegrade Cerebral Perfusion
Ann. Thorac. Surg., December 1, 2008; 86(6): 2024 - 2024.
[Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
R. De Paulis, A. Salica, D. Maselli, R. Scaffa, A. Bellisario, and L. Weltert
Reply
Ann. Thorac. Surg., December 1, 2008; 86(6): 2024 - 2025.
[Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Ruggero De Paulis
Andrea Salica
Daniele Maselli
Raffaele Scaffa
Alessandro Bellisario
Luca Weltert
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by De Paulis, R.
Right arrow Articles by Weltert, L.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by De Paulis, R.
Right arrow Articles by Weltert, L.
Related Collections
Right arrow Great vessels

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS