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Ann Thorac Surg 2008;85:1614-1618. doi:10.1016/j.athoracsur.2007.11.027
© 2008 The Society of Thoracic Surgeons
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Original Articles: Adult Cardiac

Arterial Access Through the Right Subclavian Artery in Surgery of the Aortic Arch Improves Neurologic Outcome and Mid-Term Quality of Life

Franz F. Immer, MD*, Barbara Moser, MD, Eva S. Krähenbühl, MD, Lars Englberger, MD, Mario Stalder, MD, Friedrich S. Eckstein, MD, Thierry Carrel, MD

Department of Cardiovascular Surgery, University Hospital, Berne, Switzerland

Accepted for publication November 9, 2007.

* Address correspondence to Dr Immer, Department of Cardiovascular Surgery, University Hospital, Berne, 3010, Switzerland (Email: franzimmer{at}yahoo.de).

Presented at the Forty-fourth Annual Meeting of the Society of Thoracic Surgeons, Ft. Lauderdale, FL, Jan 28–30, 2008.


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 Discussion
 References
 
Background: We have shown that selective antegrade cerebral perfusion improves mid-term quality of life in patients undergoing surgical repair for acute type A aortic dissection and aortic aneurysms. The aim of the study was to assess the impact of continuous cerebral perfusion through the right subclavian artery on immediate outcome and quality of life.

Methods: Perioperative data of 567 consecutive patients who underwent surgery of the aortic arch using deep hypothermic circulatory arrest have been analyzed. Patients were divided into three groups, according to the management of cerebral protection. Three hundred eighty-seven patients (68.3%) had deep hypothermic circulatory arrest with pharmacologic protection with pentothal only, 91 (16.0%) had selective antegrade cerebral perfusion and pentothal, and 89 (15.7%) had continuous cerebral perfusion through the right subclavian artery and pentothal. All in-hospital data were assessed, and quality of life was analyzed prospectively 2.4 ± 1.2 years after surgery with the Short Form-36 Health Survey Questionnaire.

Results: Major perioperative cerebrovascular injuries were observed in 1.1% of the patients with continuous cerebral perfusion through the right subclavian artery, compared with 9.8% with selective antegrade cerebral perfusion (p < 0.001) and 6.5% in the group with no antegrade cerebral perfusion (p = 0.007). Average quality of life after an arrest time between 30 and 50 minutes with continuous cerebral perfusion through the right subclavian artery was significantly better than selective antegrade cerebral perfusion (90.2 ± 12.1 versus 74.4 ± 40.7; p = 0.015).

Conclusions: Continuous cerebral perfusion through the right subclavian artery improves considerably perioperative brain protection during deep hypothermic circulatory arrest. Irreversible perioperative neurologic complications can be significantly reduced and duration of deep hypothermic circulatory arrest can be extended up to 50 minutes without impairment in quality of life.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 Discussion
 References
 
Surgery of the thoracic aorta and especially of the aortic arch is still associated with a considerable mortality and morbidity. Besides technical success and general outcome, quality of life (QoL) after major surgical interventions is of increasing interest. It has been shown that cerebral oxygen metabolism rate of the brain at 20°C body temperature is still around 23% and allows a safe circulatory arrest up to 20 minutes [1, 2]. The introduction of antegrade cerebral perfusion allows the safe increase of duration of deep hypothermic circulatory arrest (DHCA). Our group has recently shown that selective antegrade cerebral perfusion (SACP) improves QoL for all durations of DHCA and allows safe extension of DHCA up to 30 minutes [3]. In addition, several studies have shown that the incidence of neurologic complications can be decreased by introducing SACP in the clinical routine. Selective antegrade cerebral perfusion is performed by introducing thin perfusion catheters in the innominate artery and in the left common carotid artery. Alternatively, the right subclavian artery can be cannulated for cardiopulmonary bypass, and during DHCA perfusion of the brain can be performed by clamping or occluding the innominate artery by balloon catheter [4–14].

The aim of the study was to assess the impact of antegrade cerebral perfusion through the right subclavian artery (RAACP) on immediate neurologic outcome and mid-term QoL.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 Discussion
 References
 
Data of 567 patients who underwent surgery of the aortic arch using DHCA at our institution were analyzed. All patients signed an informed consent at admission. The study protocol was approved by the local ethical committee. According to the type of cerebral protection, patients were divided into three groups: group 1 (387 patients; 68.3%) without cerebral protection, group 2 (91 patients; 16.0%) with SACP, and group 3 (89 patients; 15.7%) with RAACP. All preoperative, intraoperative, and postoperative data were assessed and are summarized in Table 1. Patients underwent neurologic examination on the intensive care unit and, if neurologic deficits were found, a computed tomographic or magnetic resonance imaging scan of the brain was performed. Quality of life was assessed using the Short Form-36 Health Survey Questionnaire (SF-36) [15–17]. Details of this validated questionnaire to assess subjective QoL have been published previously [3]. The SF-36 consists of 36 short questions reflecting QoL in eight different aspects: bodily pain (abbreviated BP, 2 items); mental health (MH, 5); vitality (VT, 4); social functioning (SF, 2); general health (GH, 5); physical functioning (PF, 10); and role functioning, both emotional (RE, 3) and physical (RP, 4). Role functioning reflects the impact of emotional and physical disability on work and regular activity (the individual's normal everyday role). Raw points were transformed, generating a score for each dimension ranging from 0 to 100, with 100 reflecting best functioning. Swedish normal population (n = 8,930) scores are used as a standard population for comparison (range, 85 to 115). Results were compared for the three previously defined groups of modality of cerebral protection. As the primary language of the majority of our patients is German, we used the German version of the SF-36, although several languages are spoken in Switzerland. Consequently, among the cases in which the questionnaire was not answered, the majority was caused by language problems as most of the Italian and many of the French-speaking patients were not able to answer such a questionnaire in a foreign language. However, as we have previously shown, patient characteristics are not different among the different languages [18, 19]. Despite these language problems, follow-up was complete: 87.3% of the patients could be reached, and the SF-36 questionnaire was correctly filled out in greater than 80% of the patients.


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  		Table 1 Data for Group 1 Without Antegrade Cerebral Protection (n = 387), Group 2 With Selective Antegrade Cerebral Protection (n = 91), and Group 3 With Right Axillary Artery Cerebral Perfusion (n = 89)
 
Surgical Procedures
Mean operation time was 229 ± 69 minutes in group 1, 248 ± 72 minutes in group 2, and 254 ± 65 minutes in group 3 (not significant). Pentothal, at a dosage of 15 to 20 mg/kg, was administered in all patients 2 to 3 minutes before initiation of DHCA. All patients have been monitored with the bispectral index. Body temperature at the time of DHCA was set at 20°C measured in the urinary bladder with a special catheter.

The temperature of the perfusate for SACP was set at 12°C and applied between 14°C and 16°C. Selective antegrade cerebral perfusion during DHCA with oxygenated blood was performed by means of a catheter in the left common carotid artery and in the innominate artery with a pressure of 30 to 40 mm Hg corresponding to a flow of 150 to 250 mL/min. The catheters were introduced after opening the aorta under visual control. We started to use SACP during DHCA in June 2000. Cerebral perfusion during DHCA was mainly applied in patients with an expected circulatory arrest of more than 20 minutes. In RAACP the right subclavian artery was cannulated in its infraclavicular segment directly by inserting an 8F cannula, and the perfusate was set at 12°C and applied between 14°C and 16°C. No side graft cannulation was performed in this group. Oxygenated whole blood was given at a flow of 1,000 to 1,500 mL/min (owing to the drainage of the right internal thoracic artery, which is proximal from the site of cannulation) with a similar pressure of 30 to 40 mm Hg, also measured at the tip of the cannula. In RAACP perfusion, the supraaortic vessels are clamped. The superior caval vein is not clamped during surgery in this group. Antegrade cerebral perfusion through the right subclavian artery was introduced in clinical routine in 2004.

Statistical Analysis
Data are presented as mean values ± one standard deviation. A Mann-Whitney U test and {chi}2 test were used for comparison among groups of continuous and nominal variables, respectively. A probability value of less than 0.05 was considered significant.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 Discussion
 References
 
Patient Characteristics
Patient characteristics are summarized in Table 1. Acute aortic dissection type A was more frequent in patients who underwent DHCA with RAACP than in patients with SACP. Otherwise, the preoperative characteristics were similar in all three groups. Postoperative persistent neurologic deficits were found in 6.5% of patients in group 1, in 9.8% of patients in group 2, and in 1.1% of patients in group 3. Computed tomographic or magnetic resonance imaging scan revealed 30 patients (85.7%) had embolic strokes. Transient neurologic events showed no significant difference among the three groups (Fig 1), which is similar to the other assessed morbidities and length of stay.


Figure 1
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  		Fig 1. Incidence (in) in percentage of transient and persistent neurologic events in relation to cerebral perfusion technique (group 1, without; group 2, selective antegrade cerebral perfusion [ACP]; group 3, right axillary artery [RAA] cerebral perfusion). (DHCA = deep hypothermic circulatory arrest; SF-36 = Short Form-36.)

 
Follow-Up
Quality of life was prospectively assessed in our patients after surgery. Mean follow-up was 2.4 ± 1.2 years (range, 11 to 47 months). Averaged QoL scores up to 20 minutes of DHCA were similar in all three groups and are within the reported range of an age- and sex-matched standard population. Between 20 and 30 minutes of DHCA, averaged SF-36 score was impaired in comparison with a standard population in patients who underwent DHCA without antegrade cerebral perfusion. After 30 minutes QoL was markedly impaired in the group without cerebral protection, and patients with SACP showed a value that is less than 85, reflecting significant impairment in self-reported QoL (Fig 2). In patients who underwent DHCA with RAACP, QoL was preserved for up to 50 minutes of DHCA.


Figure 2
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  		Fig 2. Influence on cerebral perfusion technique (group 1, without; group 2, selective antegrade cerebral perfusion [ACP]; group 3, right axillary artery [RAA] cerebral perfusion) on averaged Short Form-36 (SF-36)-score (±1 standard deviation) in relation to the duration of deep hypothermic circulatory arrest (DHCA: <20 minutes, 20 to 30 minutes, >30 to 50 minutes). (ns = not significant.)

 
Subgroup analyses of the eight different aspects assessed with the SF-36 revealed that limitations are mainly found in the aspects of vitality and social and physical function.

Eighteen patients (20.2%) in group 3 reported neurologic symptoms of the right arm after cannulation of the right axillary artery. Further neurologic examinations revealed in 2 patients a plexus-related dysfunction of the right arm. In the remaining 16 patients the findings were inconstant and not related to a dysfunction of the right brachial plexus. In group 2, patients with SACP, neurologic symptoms have been reported in 2 patients (2.2%), both of them known for persistent cerebrovascular incident at discharge.


   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
Discussion
 References
 
Cannulation of the right subclavian artery for arterial return during cardiopulmonary bypass and for antegrade cerebral perfusion in patients with aortic arch disease has been described by Sabik and colleagues in 1995 [20]. Evaluation of this technique, mainly in small groups, showed good results in term of reduction of mortality and morbidities [4–6, 10, 13, 14]. Beside these advantages, a few series reported technical problems and complications of axillary artery cannulation [5, 20, 21]. In fact, 20.2% of our patients reported neurologic problems (sensation or motor) of the right arm after RAACP, which is related to the proximity of the right brachial plexus, favoring local complications directly related to preparation technique of the axillary artery or distal clamping. In 2 patients only (2.2%), neurologic examinations revealed a persistent injury of the brachial plexus or part of it. In the other cases minor neurologic disturbances have been reported by the patients.

A significant reduction of major neurologic complications was observed in our study, after RAACP, in comparison with the other two groups. Only in 1.1% of the patients who received RAACP was a persistent neurologic deficit found, which is lower than the data of 2.5% to 14% previously reported in the literature [7, 13, 14]. In our opinion the reduction of persistent neurologic deficit in comparison with data obtained in group 2 with SACP (incidence of 9.8%) is probably influenced by the reduced manipulation necessary to introduce balloon catheters in the supraaortic vessels, increasing the risk of thromboembolic events or air embolisms. An additional advantage of RAACP is the fact that as there are no additional catheters in the surgical field, this facilitates the surgical technique. However, the supraaortic vessels are clamped in RAACP. The observed difference in the flow rate between the two techniques is mainly caused by the drainage of the right internal thoracic artery, which is proximal to the site of cannulation in RAACP. Antegrade cerebral perfusion is applied under pressure control, with a target pressure at the tip of the cannula of 30 to 40 mm Hg or even a little bit higher. In our institution antegrade cerebral perfusion is applied without clamping of the superior vena cava, which also allows us to decrease the gradient between the site of arterial cannulation and the venous backflow.

Self-reported QoL in patients who underwent elective surgery for aortic aneurysms is better than in patients with acute type A aortic dissections. We have shown that this is related to shorter duration of DHCA and is not influenced by the type of the disease [18]. Therefore QoL results can be analyzed in relation to the duration of DHCA, independently of the type of disease.

As previously reported by our group, QoL is preserved in patients undergoing surgery of the aortic arch under DHCA (core temperature of 20°C) up to 20 minutes without cerebral perfusion and up to 30 minutes with SACP [3]. Reduction of cerebral oxygen metabolism rate with decreasing temperature, as reported by Ehrlich and colleagues [1] and McCullough and coworkers [22] in humans and in pigs, may sustain our findings. At a core temperature of 20°C, cerebral metabolism is still approximately 20% of its normal level, which favors a diffuse brain damage, as there is no regulated blood flow and no constant supply for the brain of glucose and oxygen [1, 2]. Additional cooling may reduce cerebral metabolism based on slower chemical processes and reduced enzyme activities. However, negative effects of deep hypothermia on proteins and chromatin condensation have to be taken into account [1].

In patients with impaired QoL, the SF-36 revealed limitations mainly in the aspects of vitality and physical and social function. Patients complain about fatigue, lack of concentration, and difficulties in participating in social events. Neuropsychological examinations of these patients revealed a slight but diffuse brain damage. Antegrade cerebral perfusion through the right subclavian artery allows the extension of DHCA to at least 50 minutes with no impairment in self-reported age- and sex-matched QoL. There are not enough patients to draw conclusions on QoL in patients who receive DHCA longer than 50 minutes.

We conclude that RAACP is the most simple and efficient method for perioperative cerebral protection during DHCA. Irreversible perioperative neurologic complications are significantly reduced, and duration of DHCA can be extended up to at least 50 minutes without impairment in QoL compared with an age- and sex-matched standard population.


   Discussion
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Discussion
References
 
DR THOMAS D. MARTIN (Gainesville, FL): I didn't see where you had looked at age as a factor as to whether there was a difference, and I would assume that probably you did.

1) Was there a difference in age in the groups? 2) I didn't see a year difference. I would assume that you probably did your antegrade and your axillary artery perfusion in the latter years of your study. And were those questionnaires that you sent out all sent out at the same time so that the patients who received the questionnaires when you did the no perfusion probably came from—I'm assuming, and you can correct me—came from the early years, and were they a lot longer out from the time of surgery, meaning that they were older and may have decreased quality of life?

DR STALDER: First, the population was similar. Also, the age was not different in all three groups of cerebral protection. We only found a difference in the occurring of aortic type A dissection, which even was higher in the right axillary perfusion but lower in the group with antegrade cerebral perfusion.

The second question, you are right. During this study, in the first part, there was no protection in terms of cerebral perfusion. We started to introduce the selective antegrade perfusion in 2000, and we started to introduce routinely the perfusion through the right axillary artery in 2004. But this does not influence the outcome of quality of life because we analyzed our population ongoing. That means the follow-up I showed of 2.4 years is on average. The patients got the SF-36 form after 2.4 years plus/minus.

DR GUS J. VLAHAKES (Boston, MA): You mentioned in the manuscript that the cannulation is done directly with an 8-French cannula as opposed to the use of a side-arm graft. Could you comment on whether you've had any issues related to the subsequent repair of the artery or anything in late follow-up?

DR STALDER: We looked also at the local complications of the cannulation site and those of the arm, and we found in 2% of the patients who were cannulated directly an impairment of neurologic function of the arm, and also found after evaluation that it was a deficit of the plexus assuming that during cannulation the plexus was somehow injured.

The closing, I think, as far as I remember, we didn't look at that generally on the data. But in my experience, when the axillary artery is dissected, especially in type A dissections, it can be quite difficult to close it. But as far as I know, and those that are in our data, we never had problems with perfusion of the right arm.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Discussion
 References
 

  1. Ehrlich MP, McCullough JN, Zhang N, et al. Effect of hypothermia on cerebral blood flow and metabolism in the pig Ann Thorac Surg 2002;73:191-197.[Abstract/Free Full Text]
  2. 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]
  3. Immer FF, Lippeck C, Barmettler H, et al. Improvement of Quality of Life after surgery on the thoracic aorta. Effect of antegrade cerebral perfusion and short duration of deep hypothermic circulatory arrest. Circulation 2004;110II-250–5.
  4. Pasic M, Schubel J, Bauer M, et al. Cannulation of the right axillary artery for surgery of acute type A aortic dissection Eur J Cardiothorac Surg 2003;24:231-236.[Abstract/Free Full Text]
  5. Reuthebuch O, Schnurr U, Hellermann J, et al. Advantages of subclavian artery perfusion for repair of acute type A dissection Eur J Cardiothorac Surg 2004;26:592-598.[Abstract/Free Full Text]
  6. Moizumi Y, Motoyoshi N, Sakuma K, Yoshida S. Axillary artery cannulation improves operative results for acute type a aortic dissection Ann Thorac Surg 2005;80:77-83.[Abstract/Free Full Text]
  7. Strauch JT, Spielvogel D, Lauten A, et al. Axillary artery cannulation: routine use in ascending aorta and aortic arch replacement Ann Thorac Surg 2004;78:103-108.[Abstract/Free Full Text]
  8. Bachet J, Guilmet D, Goudot B, et al. Antegrade cerebral perfusion with cold blood: a 13-year experience Ann Thorac Surg 1999;67:1874-1878discussion 1891–4.[Abstract/Free Full Text]
  9. Schachner T, Nagiller J, Zimmer A, Laufer G, Bonatti J. Technical problems and complications of axillary artery cannulation Eur J Cardiothorac Surg 2005;27:634-637.[Abstract/Free Full Text]
  10. Di Bartolomeo R, Di Ausanio M, Pacini D, et al. Antegrade selective cerebral perfusion during surgery of the thoracic aorta: risk analysis Eur J Cardiothorac Surg 2001;19:765-770.[Abstract/Free Full Text]
  11. Di Eusanio M, Schepens MA, Morshuis WJ, Di Bartolomeo R, Pierangeli A, Dossche KM. Antegrade selective cerebral perfusion during operations on the thoracic aorta: factors influencing survival and neurologic outcome in 413 patients J Thorac Cardiovasc Surg 2002;124:1080-1086.[Abstract/Free Full Text]
  12. Pacini D, Di Marco L, Marsilli D, et al. Nine years experience of aortic arch repair with aid of antegrade selective cerebral perfusion J Cardiovasc Surg 2006;47:691-698.[Medline]
  13. Strauch JT, Bohme Y, Franke UF, Wittwer T, Madershahian N, Wahlers T. Selective cerebral perfusion via right axillary artery direct cannulation for aortic arch surgery Thorac Cardiovasc Surg 2005;53:334-340.[Medline]
  14. Shimazaki Y, Watanabe T, Takahashi T, et al. Minimized mortality and neurological complications in surgery for chronic arch aneurysm: axillary artery cannulation, selective cerebral perfusion, and replacement of the ascending and total arch aorta J Card Surg 2004;19:338-342.[Medline]
  15. Ware JE, Snow KK, Kosinski M, et al. SF-36 health survey manual and interpretation guideBoston, MA: New England Medical Center, The Health Institute; 1993.
  16. Sullivan M, Karlsson J, Ware JE. SF-36 health questionnaire. Swedish manual and interpretation guide. Gothenburg Sweden: Gothenburg University; 1994.
  17. Bland JM, Altmann DG. Statistics notes. Cronbach's alpha. BMJ 1997;314:572.[Free Full Text]
  18. Immer FF, Krähenbühl ES, Immer-Bansi AS, et al. Quality of life after inventions on the thoracic aorta with deep hypothermic circulatory arrest Eur J Cardiothorac Surg 2002;21:10-14.[Abstract/Free Full Text]
  19. Immer FF, Barmettler H, Berdat PA, et al. Effects of deep hypothermic circulatory arrest on outcome after resection of ascending aortic aneurysm Ann Thorac Surg 2002;74:422-425.[Abstract/Free Full Text]
  20. Sabik JF, Lytle BW, McCarthy PM, Cosgrove DM. Axillary artery: an alternative site of arterial cannulation for patients with extensive aortic and peripheral vascular disease J Thorac Cardiovasc Surg 1995;109:885-890.[Abstract]
  21. Gurbuz A, Emrecan B, Yilik L, et al. Aortic reoperations: Experience with 23 patients using axillary artery cannulation Int Heart J 2005;46:1099-1104.[Medline]
  22. 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]



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