| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Ann Thorac Surg 2000;70:15-16
© 2000 The Society of Thoracic Surgeons
a First Department of Surgery, Hamamatsu University School of Medicine, 3600 Handa-Cho, Hamamatsu 431-3192, Japan
I congrtulate Di Bartolomeo and coauthors for the outstanding results they have achieved using antegrade selective cerebral perfusion as the method of cerebral protection during thoracic aortic operations. Considering that about one third of the patients in their series had emergency operations, an 8.8% early mortality rate, a 5.3% rate of temporary neurologic dysfunction, and a zero incidence of permanent neurologic dysfunction are truly impressive figures. Some of these percentages may appear unrealistic. However, the most recent results obtained by my colleagues and me testify that they are fairly attainable. Using our newly developed cerebral perfusion cannula, we have performed 25 total arch replacements over the last 10 months. There were no hospital deaths, no permanent neurologic deficits, and a 4% rate of temporary neurologic dysfunction.
Selective cerebral perfusion is still considered by many surgeons to be an instrument-intensive cumbersome procedure. However, the technique that we have described [1–4] and that was followed by Di Bartolomeo and associates is much simpler than the conventional selective cerebral perfusion techniques and is easily reproducible. Selective cerebral protection that antegradely supplies oxygenated blood to the brain in sufficient amounts is physiologically superior to other methods of cerebral protection. Moreover, because it is basically free from any time limitation in regards to its protective function, our method allows enough time to perform more aggressive replacements whenever necessary. For example, when undertaking total arch replacement using an aortic arch branched graft, we sometimes perform concomitant replacement of the ascending aorta, the proximal descending aorta, or both because of the presence of atherosclerotic plaques that can give rise to subsequent embolic events. Though such aggressive approaches make the operation more extensive, they pay off in the postoperative period by reducing the incidence of neurologic deficits.
Two recent modifications to our operative technique include inserting the arterial cannula into the ascending aorta whenever possible and starting antegrade systemic perfusion through the branch attached to the arch graft after completing the distal graft anastomosis. This is done to prevent embolization from the distal aorta. In addition, during the distal graft anastomosis the systemic circulation is completely arrested at a rectal temperature of 22°C. This allows us to extend that anastomosis to the level of the hilum of the lung without opening the left chest cavity.
One of the key technical points in selective cerebral perfusion is the arch vessel cannulation. It is very important to transect the vessels at places where they are intact to avoid dislodgment of atherosclerotic debris, commonly located at their origins. Also, while cannulating, care should be taken to maintain the blood perfusion to eliminate possible air emboli. In cases of acute dissection, it is not difficult to distinguish between the true and false lumens from the arch or the ascending aorta, and cannulation through the true lumen can be done fairly easily. The design of the cannula that we use now is very convenient because it can be bent at right angles with the help of flexible metallic support and allows pressure monitoring.
I strongly believe that with increasing experience and expertise, we can do still better with selective cerebral perfusion.
References
Related Article
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 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 |
