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Ann Thorac Surg 2008;86:1827-1831. doi:10.1016/j.athoracsur.2008.07.024
© 2008 The Society of Thoracic Surgeons
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Original Articles: Adult Cardiac

Evolving Selective Cerebral Perfusion for Aortic Arch Replacement: High Flow Rate With Moderate Hypothermic Circulatory Arrest

Kenji Minatoya, MD*, Hitoshi Ogino, MD, PhD, Hitoshi Matsuda, MD, PhD, Hiroaki Sasaki, MD, PhD, Hiroshi Tanaka, MD, PhD, Junjiro Kobayashi, MD, Toshikatsu Yagihara, MD, PhD, Soichiro Kitamura, MD, PhD

Department of Cardiovascular Surgery, National Cardiovascular Center, Suita, Osaka, Japan

Accepted for publication July 9, 2008.

* Address correspondence to Dr Minatoya, Department of Cardiovascular Surgery, National Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka, 5658565, Japan (Email: minatoya{at}hsp.ncvc.go.jp).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 References
 
Background: Although hypothermic circulatory arrest (HCA) combined with selective cerebral perfusion (SCP) is a safe strategy for aortic arch surgery, neither the optimal temperature of hypothermia nor the optimal SCP flow rate has been clearly determined. We have since 2002 gradually elevated the temperature of HCA from 20°C to 28°C for aortic arch surgery. This study explored the impact of different temperatures during HCA with SCP on neurologic complications.

Methods: Since January 2002, 229 patients have undergone aortic arch replacement (mean age, 70.8 ± 9.7 years; 156 male) with HCA and SCP through median sternotomy in our institution. Eighty-one patients were cooled to 20°C (group A), 81 were cooled to 25°C (group B), and 67 were cooled to 28°C (group C). The brachiocephalic and left common carotid arteries were perfused separately during SCP in all cases. The left subclavian artery was additionally perfused in group C. Twenty-two operations in group A, 17 in group B, and 6 in group C were performed emergently (p = 0.58). The SCP flow rate was maintained at approximately 10 mL · kg–1 · min–1 in groups A and B and approximately 15 mL · kg–1 · min–1 in group C to keep blood pressure in the temporal artery at approximately 60 mm Hg.

Results: The early mortality rate was 3.7% (3 of 81) in group A, 0% in group B, and 1.5% (1 of 67) in group C (p = 0.19). Postoperative stroke occurred in 2 patients (2.5%) in group A, in 3 (3.7%) in group B, and in 4 (6.0%) in group C (p = 0.55). Postoperative transient neurologic dysfunction occurred in 7 patients (8.6%) in group A, in 9 patients (11.1%) in group B, and in 4 patients (6.0%) in group C (p = 0.54). No patients in any group had postoperative paraplegia. The mean durations of circulatory arrest were 64 ± 21 minutes in group A, 49 ± 14 minutes in group B, and 46 ± 13 minutes in group C (p < 0.0001). The mean durations of SCP were 145 ± 67 minutes in group A, 116 ± 48 minutes in group B, and 111 ± 61 minutes in group C (p = 0.0007). Mean SCP flow rates were 8.8 ± 1.9 mL · kg–1 · min–1 in group A, 10.5 ± 3.1 mL · kg–1 · min–1 in group B, and 19.0 ± 4.2 mL · kg–1 · min–1 in group C (p < 0.0001).

Conclusions: The rate of postoperative neurologic events did not increase with use of higher temperature. The temperature during HCA could be safely increased to 28°C with high SCP flow rate. Use of moderate HCA with SCP during aortic arch replacement permits radical reconstruction of the aortic arch and can avoid the need for deep hypothermia.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 References
 
Neurologic events are among the most devastating complications of aortic surgery. Although use of adjunctive techniques such as antegrade selective cerebral perfusion (SCP) or retrograde cerebral perfusion (RCP) have yielded better results in many studies [1], the basic method of neurologic protection during aortic surgery is still hypothermic circulatory arrest (HCA). Deep hypothermia is required when prolonged periods of possible brain ischemia are anticipated [2], and in such cases, body temperature has been lowered to near 20°C. However, because deep hypothermia is associated with an increased risk of bleeding and increased rate of blood transfusion, many institutions have recently attempted to elevate body temperature [3–7].

Although HCA combined with SCP is a safe strategy for aortic arch surgery, neither the optimal temperature of hypothermia nor the optimal SCP flow rate has been clearly determined. We have since 2002 gradually elevated the temperature of HCA from 20°C to 28°C for aortic arch surgery. This study explored the impact of different temperatures during HCA with SCP on neurologic complications.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 References
 
Patients
From January 2002 to February 2005, 229 patients underwent aortic arch replacement (mean age, 70.8 ± 9.7 years; 156 male) with HCA and SCP through median sternotomy in our institution. One hundred seventy-eight patients with chronic lesions underwent elective surgery, and 51 underwent emergent surgery. The reason for emergency surgery was acute aortic dissection in 39 patients and rupture of chronic aneurysm in 12 patients. One hundred eighty-five patients underwent total arch replacement, and 44 underwent hemiarch replacement. Eighty-one patients were cooled to 20°C (group A), 81 patients to 25°C (group B), and 67 patients to 28°C (group C). Mean age was 70.8 ± 9.7 years in group A, 71.1 ± 8.4 years in group B, and 70.4 ± 11.3 years in group C. Table 1 shows demographic data of the population, and Table 2 shows preoperative morbidity of the population. Our institution approved this retrospective study and waived patient consent on the condition that patients are not identified.


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  		Table 1 Patient Demographics
 

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  		Table 2 Preoperative Morbidity
 
Operative Techniques
The skin incision extended from the suprasternal notch to a point equidistant from the xiphoid process and umbilicus. A left hemicollar incision was added to improve exposure of the branches of the aortic arch. All operative maneuvers were performed through a median sternotomy.

The femoral artery or ascending aorta was used as a site of cannulation for arterial return. Ascending cannulation is preferable when atherosclerotic change in the ascending aorta is minimal on epiaortic echography, although femoral arterial cannulation is opted for when the ascending aorta has severe atherosclerotic changes or there is acute aortic dissection. Additional cannulation into the right axillary artery was performed in most cases (97.8%) [8, 9]. The patients were cooled using the {alpha}-stat method of pH control until nasopharyngeal temperature reached 20°C (group A), 25°C (group B), or 28°C (group C). Reperfusion and rewarming were always performed in antegrade fashion through the side branch of the graft. A collagen woven or gelatin-impregnated knitted Dacron (C.R. Bard, Haverhill, Pennsylvania) graft was used for graft replacement. One branched graft was used for hemiarch replacement, and a quadrifurcated graft was used for total arch replacement. When total arch replacement was performed, arch vessels were independently reconstructed using a quadrifurcated graft without the en-bloc repair technique.

Open distal anastomosis was performed in all cases. The anastomosis was always performed with complete transection of the descending aorta distal to the left subclavian artery for total arch replacement, and with complete transection of the aortic arch for hemiarch replacement. Stepwise technique was employed for distal anastomosis in most cases of total arch replacement [10]. A short graft was introduced into the lumen of the descending aorta from the stump, and then sewn to the aortic wall with running 3-0 or 4-0 polypropylene suture. The short graft was then pulled out of the descending aorta. At the suture line, the graft was inverted circumferentially and fixed to the aortic wall in appropriate fashion. This suture line may in rare cases bleed, although if bleeding occurs, it is easily stopped with an additional stitch. Finally, the quadrifurcated graft was anastomosed to the short graft with running 3-0 polypropylene suture. That was followed by anastomosis of the left subclavian artery, proximal anastomosis to the ascending aorta, reconstruction of the left internal carotid artery, and final anastomosis of the brachiocephalic artery. Rewarming was commenced after the reconstruction of the left subclavian artery.

Selective cerebral perfusion was performed with an ordinary arterial cannula in the right axillary artery or with a balloon-tip cannula inserted directly into the brachiocephalic artery from inside the aortic arch and into the left common carotid artery. The left subclavian artery was clamped in groups A and B, and was perfused with a balloon-tip cannula in group C. Selective cerebral perfusion was continued until all branches of arch were reconstructed. Cerebral perfusion was regulated to maintain the mean pressure in the superficial temporal arteries at 60 mm Hg. Monitoring of the perfusion pressure in the bilateral superficial temporal arteries was performed using standard methods in most cases. However, perfusion pressure measured at the top of the perfusion balloon was used when the temporal arteries were not available.

For reinforcement of the stump of the aorta in cases of acute aortic dissection, gelatin-resorcin-formaldehyde (GRF) glue or Bioglue Surgical Adhesive (CryoLife, Kennesaw, Georgia) was applied to obliterate the false lumen in most cases. In addition to usage of chemical glue, all stumps were reinforced with Teflon (Impra, subsidiary of L.R. Bard, Tempe, Arizona) felt strips. For total arch replacement, Teflon felt strips were placed on the outer side of aortic stump, and a graft 5 to 7 cm in length and 18 to 22 mm in diameter was inserted into the true lumen of the descending aorta as an elephant trunk. They were sutured and fixed with running 5-0 polypropylene suture, obliterating the false lumen in sandwichlike fashion. The quadrifurcated graft was anastomosed to the stump of the descending aorta, where sandwichlike reinforcement was applied. For hemiarch replacement, Teflon felt strips were placed on the outer and inner sides of the aortic stump. The stump was thus reinforced and the false lumen obliterated in sandwichlike fashion with running 5-0 polypropylene suture.

Concomitant Procedures
Concomitant procedures included aortic valve resuspension in 16 patients, aortic valve replacement in 13, aortic root replacement in 8, mitral valve operations in 5, and coronary artery grafting in 33 patients.

Definitions
Early mortality was defined as death within the hospital. Postoperative stroke was defined as newly developing neurologic deficit, with confirmation by computed tomography. Transient neurologic dysfunction was defined as postoperative confusion, agitation, delirium, or prolonged obtundation with a negative brain computed tomography scan and complete resolution before discharge. The neurologic diagnosis was made by neurologists.

Statistical Analysis
Values are the mean ± SD. Data were analyzed using the {chi}2 test for categorical variables, and continuous variables were examined with analysis of variance (ANOVA).


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 References
 
The early mortality rate was 3.7% (3 of 81) in group A, 0% in group B, and 1.5% (1 of 67) in group C (p = 0.19). All 3 patients in group A who had early death had undergone emergent surgery for acute aortic dissection. The patient in group C had mega-aortic syndrome and underwent two-stage operation. He successfully underwent the first aortic arch operation, but died of multiorgan failure after the second operation for thoracoabodominal aortic aneurysm performed a few weeks after the first operation. Postoperative stroke occurred in 2 patients (2.5%) in group A, 3 patients (3.7%) in group B, and 4 patients (6.0%) in group C (p = 0.55). Of the 9 patients who had a postoperative stroke, 6 underwent emergent surgery. Seven patients (8.6%) had postoperative transient neurologic dysfunction in group A, 9 (11.1%) in group B, and 4 (6.0%) in group C (p = 0.54). No patients had postoperative paraplegia in any group. Postoperative recurrent laryngeal nerve palsy occurred in 8 patients (9.9%) in group A, 4 (4.9%) in group B, and 2 (3.0%) in group C (p = 0.19). No patient had chylothorax in group A and B, but 3 did in group C (p = 0.03).

The mean durations of cardiopulmonary bypass were 234 ± 116 minutes in group A, 202 ± 64 minutes in group B, and 206 ± 61 minutes in group C (p < 0.03). The mean durations of circulatory arrest were 64 ± 21 minutes in group A, 49 ± 14 minutes in group B, and 46 ± 13 minutes in group C (p < 0.0001). The mean durations of SCP were 145 ± 67 minutes in group A, 116 ± 48 minutes in group B, and 111 ± 61 minutes in group C (p = 0.0007). Mean SCP flow rate was 8.8 ± 1.9 mL · kg–1 · min–1 in group A, 10.5 ± 3.1 mL · kg–1 · min–1 in group B, and 19.0 ± 4.2 mL · kg–1 · min–1 in group C (p < 0.0001). Transfusion volume was 3,689 ± 4,200 mL in group A, 4,050 ± 3,322 mL in group B, and 3,643 ± 3,159 mL in group C (p = 0.74). The rates of requirement of platelet transfusion were 63.0% in group A, 67.9% in group B, and 46.3% in group C (p = 0.0066). Lactate levels at admission to the intensive care unit after surgery were 3.9 ± 2.3 mmol/L in group A, 3.1 ± 1.5 mmol/L in group B, and 3.0 ± 1.5 mmol/L in group C (p = 0.007).

To clearly determine the impact of SCP with HCA, the subset of patients who underwent elective total arch replacement for chronic aortic pathology without concomitant surgery was examined. This population consisted of 37 patients in group A, 44 in group B, and 33 in group C. Table 3 shows preoperative morbidity in this subset. No significant differences among groups were found in this subset for any of the factors examined. The early mortality rate was 0% in group A (0 of 37 patients), 0% in group B (0 of 44), and 3.0% (1 of 33) in group C (p = 0.29). The patient in group C was the one with mega-aortic syndrome described above. One patient (2.7%) had a postoperative stroke in group A, 0 in group B, and 1 (3.0%) in group C (p = 0.52). Postoperative transient neurologic dysfunction occurred in 5 patients (13.5%) in group A, 4 (9.1%) in group B, and 0 in group C (p = 0.10). Table 4 shows the other results.


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  		Table 3 Preoperative Morbidity of Elective Total Arch Replacement Without Concomitant Procedures
 

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  		Table 4 Operative Variables
 

   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
References
 
Regulation of flow to the brain during SCP should be performed to keep the perfusion pressure within the range allowing cerebral autoregulation to preclude cerebral ischemia or hyperperfusion [11]. Kazui and colleagues [12] reported their methods with SCP in 1992 that included cooling of rectal temperature to 20° to 22°C with a selective cerebral flow rate of 10 mL · kg–1 · min–1. Cerebral perfusion pressure was adjusted by monitoring the right radial artery pressure, which was maintained at 60 to 80 mm Hg. Selective cerebral perfusion flow rates used clinically have been based on the results of their experimental study [13], and perfusion pressure is thought to be more important than flow rate for brain protection. Autoregulation of the cerebral circulation maintains relatively constant cerebral blood flow within a range of perfusion pressures. The constancy of cerebral blood flow is achieved by dilatation or constriction of cerebral resistance vessels in response to changes in perfusion pressure.

Henriksen and colleagues [14] reported that perfusion pressure less than 55 mm Hg was significantly correlated with a decrease in cerebral blood flow, indicating that cerebral autoregulation was lost below this level. This conclusion is widely accepted in the performance of aortic arch surgery. Although the flow was around 10 mL · kg–1 · min–1 in groups A and B, the selective cerebral flow rate was increased to 19.0 mL · kg–1 · min–1 in group C to keep the perfusion pressure near 60 mm Hg in the present study. This flow rate was almost twice that in groups A and B. The rate of postoperative neurologic complications was not affected by this high rate of SCP flow.

Our findings suggest that use of SCP has a sound physiologic basis at predetermined target perfusion pressures rather than fixed flow rates. There may be two principal reasons for the need for this high rate of flow. One is the increase in metabolic demand on the brain with warmer temperature. It is possible that vascular resistance changes to meet metabolic demands of the brain, with higher flow rate required to meet this demand. Another possible reason is increase in collateral circulation from the axillary and subclavian arteries, which connect to the systemic circulation. The vascular tone of the branches of the arteries may be decreased at higher temperature, leading to higher blood flow. Although several groups also using moderate hypothermia with SCP reported SCP flow rates different from our own, they perfuse the brain directly using only arch vessels. Touati and colleagues [15] reported totally normothermic aortic arch replacement without circulatory arrest. Their cerebral pump flow rates to maintain the right radial artery pressure at 70 mm Hg or more varied from 680 mL/min to 1,100 mL/min, which are flow rates not as high as ours. Jacobs and colleagues [6] used a higher SCP flow rate of 15 mL · kg–1 · min–1 when performing elective aortic arch operations under moderate hypothermic circulatory arrest.

Another concern is spinal ischemia when circulatory arrest with moderate hypothermia is employed. Despite the accumulation of findings on circulation in the vertebral spine, no method yet exists to completely prevent spinal ischemia. Although we started the third cannulation at the left subclavian artery for SCP, expecting an increase in blood perfusion in spinal cord when we raised the temperature, we in fact observed spurting of blood from numerous intercostal arteries inside the descending aorta when a high SCP flow rate was applied in group C. Although the origin of this backflow from the intercostal arteries is unknown, it may be the bilateral internal mammary arteries. The internal mammary arteries are connected to the subclavian arteries, which are perfused with high flow. The vertebral artery, which connects to the subclavian artery, is another important source of flow to the anterior cerebral artery. The safe duration of circulatory arrest at 28 °C for prevention of spinal ischemia has yet to be determined. However, the high flow rate of SCP might contribute to sufficient perfusion of the spinal cord and prevent spinal ischemia during circulatory arrest at this temperature. In group C, several patients were restarted at lower body perfusion using femoral artery cannulation, because of concerns related to spinal ischemia. We believe that this maneuver significantly shortened HCA in group C.

In conclusion, use of SCP appears to have a sound physiologic basis at predetermined target perfusion pressures rather than fixed flow rates under autoregulation of cerebral blood flow. The temperature during HCA could be raised to 28°C safely with high SCP flow rate. The rate of postoperative neurologic events was not increased with higher temperature under HCA with SCP. No spinal ischemia was observed. Use of moderate HCA with SCP during aortic arch replacement permits radical reconstruction of the aortic arch and can avoid the need for deep hypothermia.

Study Limitations
This study was performed using a retrospective nonrandomized design in the clinical setting of aortic arch surgery. The conclusions obtained from the observations performed on the three nonrandomized groups may, therefore, represent a source of bias in the comparisons. To overcome the limitations, a prospective randomized study should be performed.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 

  1. Okita Y, Minatoya K, Tagusari O, Ando M, Nagatsuka K, Kitamura S. Prospective comparative study of brain protection in total aortic arch replacement: deep hypothermic circulatory arrest with retrograde cerebral perfusion or selective antegrade cerebral perfusion Ann Thorac Surg 2001;72:72-79.[Abstract/Free Full Text]
  2. Svensson LG. Central nervous system injury after aortic operations: profits of amending old ways Ann Thorac Surg 1997;63:9-11.[Free Full Text]
  3. Bachet J, Guilmet D, Goudot B, et al. Antegrade cerebral perfusion with cold blood: a 13-year experience Ann Thorac Surg 1999;67:1874-1894.[Abstract/Free Full Text]
  4. Kazui T, Inoue N, Yamada O, Komatsu S. Selective cerebral perfusion during operation for aneurysms of the aortic arch: a reassessment Ann Thorac Surg 1992;53:109-114.[Abstract/Free Full Text]
  5. Dossche KM, Morshuis WJ, Schepens MA, Waanders FG. Bilateral antegrade selective cerebral perfusion during surgery on the proximal thoracic aorta Eur J Cardiothorac Surg 2000;17:462-467.[Abstract/Free Full Text]
  6. Jacobs MJ, de Mol BA, Veldman DJ. Aortic arch and proximal supraaortic arterial repair under continuous antegrade cerebral perfusion and moderate hypothermia Cardiovasc Surg 2001;9:396-402.[Medline]
  7. Di Bartolomeo R, Di Eusanio 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]
  8. Numata S, Ogino H, Sasaki H, et al. Total arch replacement using antegrade selective cerebral perfusion with right axillary artery perfusion Eur J Cardiothorac Surg 2003;23:771-775.[Abstract/Free Full Text]
  9. Minatoya K, Ogino H, Matsuda H, Sasaki H. Rapid and safe establishment of cardiopulmonary bypass in repair of acute aortic dissection: improved results with double cannulations. Interact Cardiovasc Thorac Surg. In press.
  10. Sasaki H, Ogino H, Matsuda H, Minatoya K, Ando M, Kitamura S. Integrated total arch replacement using selective cerebral perfusion: a 6-year experience Ann Thorac Surg 2007;83(Suppl):805-810discussion 824–31.
  11. Tanaka J, Shiki K, Asou T, Yasui H, Tokunaga K. Cerebral autoregulation during deep hypothermic nonpulsatile cardiopulmonary bypass with selective cerebral perfusion in dogs J Thorac Cardiovasc Surg 1988;95:124-132.[Abstract]
  12. Kazui T, Inoue N, Yamada O, Komatsu S. Selective cerebral perfusion during operation for aneurysms of the aortic arch: a reassessment Ann Thorac Surg 1992;53:109-114.[Abstract/Free Full Text]
  13. Tanaka H, Kazui T, Sato H, Inoue N, Yamada O, Komatsu S. Experimental study on the optimum flow rate and pressure for selective cerebral perfusion Ann Thorac Surg 1995;59:651-657.[Abstract/Free Full Text]
  14. Henriksen L, Hjelms E, Lindeburgh T. Brain hyperperfusion during cardiac operations. Cerebral blood flow measured in man by intra-arterial injection of xenon 133: evidence suggestive of intraoperative microembolism. J Thorac Cardiovasc Surg 1983;86:202-208.[Abstract]
  15. Touati GD, Roux N, Carmi D, et al. Totally normothermic aortic arch replacement without circulatory arrest Ann Thorac Surg 2003;76:2115-2117.[Abstract/Free Full Text]

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