Modified Technique for Retrograde Cerebral Perfusion during Hemiarch Aortic Replacement

Abstract Background Uncertainty remains regarding the optimal method of brain protection for procedures that require repair or replacement of the aortic arch. We examined the early outcomes of a technique for brain protection in patients undergoing partial aortic arch (hemiarch) replacement that involves deep hypothermic circulatory arrest (DHCA) and retrograde cerebral perfusion (RCP) of cold blood from the superior vena cava toward the end of the arrest interval. Methods During a recent 15-year interval, 520 patients underwent elective or urgent/emergent ascending aortic and hemiarch replacement as an isolated (47 patients) or combined (473 patients) procedure employing DHCA (mean nasopharyngeal temperature at circulatory arrest, 17.1°C and mean duration, 19.3 minutes) supplemented with RCP of cold blood from the superior vena cava toward the end of the arrest interval (mean, 6.7 minutes). The mean age of the patients was 59.5 years, and 65% were male. Results The in-hospital and 30-day mortality rates were 1.2% (six patients). Seven patients (1.4%) sustained a stroke and 19 patients (3.7%) had transient neurologic dysfunction that completely resolved by the time of hospital discharge. Four patients (0.77%) developed postoperative renal failure requiring dialysis. Twenty-one patients (4%) required ventilator support for >48 hours and five patients (0.96%) required a tracheostomy. The median hospital length of stay was 6 days. Conclusion DHCA with a brief interval of RCP is a safe and effective technique for brain protection during hemiarch aortic replacement. RCP reduces the duration of brain ischemia and permits removal of particulate matter and air from the arterial circulation.

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Continuous retrograde cerebral perfusion supplies substrates for brain metabolism during hypothermic circulatory arrest

Perfusion ◽

10.1177/026765919501000406 ◽

1995 ◽

Vol 10 (4) ◽

pp. 237-244 ◽

Cited By ~ 6

Author(s):

Suat Buket ◽

Alp Alayunt ◽

Berent Discigil ◽

Anil Apaydin ◽

Munevver Yuksel ◽

...

Keyword(s):

Glucose Level ◽

Superior Vena Cava ◽

Cerebral Perfusion ◽

Carotid Arteries ◽

Circulatory Arrest ◽

Superior Vena ◽

Vena Cava ◽

Hypothermic Circulatory Arrest ◽

Brain Protection ◽

Retrograde Cerebral Perfusion

Ten patients underwent replacement of ascending aorta and/or aortic arch with aneurysm or dissection, using hypothermic circulatory arrest (HCA) with retrograde cerebral perfusion (RCP). RCP was administered through the superior vena cava cannula continuously during HCA (15°C to 20°C). Mean HCA time was 32 minutes (range, 18-45 minutes). To assess the metabolic changes during RCP, blood samples were taken from carotid arteries and the superior vena cava cannula simultaneously, five minutes after the onset and five minutes prior to termination of continuous retrograde cerebral perfusion (CRCP) for analysis of blood gas and glucose level. One patient died intraoperatively due to left ventricular failure. Nine patients survived their operations and all except one with stroke due to partial intimal flap obstruction of innominate artery awoke neurologically intact within four to six hours. One patient died on the postoperative fifth day due to septic shock following resection of ischaemic bowel due to dissection involving the mesenteric artery. Oxygen saturation, pH and glucose level were all found to be lower in blood back-bleeding from the carotid arteries than in blood perfused through the superior vena cava cannula at all sampling times during HCA and CRCP (p < 0.05). Although oxygen and glucose extraction is not only from brain tissue, these data demonstrate the efficacy of CRCP in supplying substrates for brain protection. CRCP is a reliable method as an adjunct to HCA for brain protection.

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Continuous retrograde hypothermic low flow cerebral perfusion during aortic arch surgery

Perfusion ◽

10.1177/026765919400900203 ◽

1994 ◽

Vol 9 (2) ◽

pp. 95-99 ◽

Cited By ~ 6

Author(s):

Peter A. M. Everts ◽

Eric Berreklouw ◽

Monique M. M. Hessels ◽

Jacques P. A. M. Schönberger

Keyword(s):

Aortic Arch ◽

Superior Vena Cava ◽

Femoral Artery ◽

Cerebral Perfusion ◽

Circulatory Arrest ◽

Superior Vena ◽

Vena Cava ◽

Low Flow ◽

Systemic Circulatory Arrest ◽

Bypass Line

Continuous retrograde hypothermic low flow cerebral perfusion (CRCP) with deep hypothermic systemic circulatory arrest (DHSCA) during aortic arch surgery was employed in six patients, aged 21-79 years. From August 1991 to November 1992, five of these patients were operated for ascending and arch aortic dissection type I, and one patient was operated for an aneurysm extending from the ascending aorta into the arch. Cardiopulmonary bypass (CPB) technology included a centrifugal pump and low-dose aprotinin. Venous drainage was established via the superior and inferior caval veins and arterial return via the femoral artery. Prior to CPB, a bypass line connecting the arterial line with the superior vena cava cannula was implemented. Prior to DHSCA, the patients were systemically cooled to a mean nasopharyngeal temperature of 15.2°C. After induction of systemic circulatory arrest, the femoral artery cannula was clamped. Thereafter, the implemented bypass line was opened to achieve reverse flow into the superior vena cava to allow venoarterial perfusion. The perfusate was returned to the CPB circuit through drainage from the inferior caval vein and by aspiration of blood from the opened aortic arch. CRCP flow rate ranged from 250 to 450 ml/min (mean 375 ml/min) maintaining an internal jugular vein pressure between 18 and 25 mmHg. The duration of CRCP ranged from 24 to 55 minutes (mean 39 minutes). Postoperatively, one patient died of cardiac failure. The other five patients regained full consciousness without neurological deficits, as defined by the Glasgow coma score, within 48 hours after the operation. Neither did we see other major organ complications. At present four patients are alive nine to 24 months after surgery and they are in New York Heart Association (NYHA) functional classification I-II. Our experience indicates that CRCP is safe and effective, avoiding cerebral circulatory arrest. Furthermore, this technique avoids clamping of cerebral vessels, reduces the chances of embolism of particulate debris and of cerebral air intrusion into opened cerebral vessels.

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Multichannel Monitoring of Cerebral Circulatory and Oxygenation Status Using Optical Topography during Deep Hypothermic Retrograde Cerebral Perfusion

Vascular ◽

10.1258/rsmvasc.12.5.325 ◽

2004 ◽

Vol 12 (5) ◽

pp. 325-330

Author(s):

Katsuhito Ueno ◽

Shinichi Takamoto ◽

Takeshi Miyairi ◽

Tetsuro Morota ◽

Ko Shibata ◽

...

Keyword(s):

Cerebral Perfusion ◽

Circulatory Arrest ◽

Superior Vena ◽

Aortic Surgery ◽

Vena Cava ◽

Retrograde Cerebral Perfusion ◽

Rate Of Increase ◽

Significant Difference ◽

Optical Topography ◽

Oxygenation Status

In this study, we evaluated changes in the cerebral circulatory and oxygenation status during deep hypothermic total circulatory arrest (TCA) and retrograde cerebral perfusion (RCP) using optical topography, a form of multichannel near-infrared spectrophotometry, to monitor the broad area perfused by the middle cerebral artery. Seven patients underwent thoracic aortic surgery with TCA and RCP via the superior vena cava. Pressure-regulated RCP was performed under pH-stat. No postoperative neurologic complications occurred. Using optical topography, the relative changes in oxy-, deoxy-, and total hemoglobin (oxy-Hb, deoxy-Hb, total Hb) were simultaneously measured from 24 points in both hemispheres. Deoxy-Hb was used for evaluating the regional oxygenation status under RCP. The values of deoxy-Hb at the beginning of RCP were regarded as the basal values, and the rate of increase in deoxy-Hb per minute was calculated at each site. Deoxy-Hb/min during TCA was also calculated. In every case, both oxy-Hb and total Hb decreased and deoxy-Hb increased during TCA. When RCP was initiated, the decrease in oxy-Hb and the increase in deoxy-Hb were attenuated. The deoxy-Hb/min was significantly lower under RCP than during TCA in all portions. There was no significant difference of deoxy-Hb/min between any portions during RCP. Our results showed that the status of circulation and oxygenation might be uniform in the brain during RCP and better than that under TCA.

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Arch-First Technique for Aortic Arch Operation Using Branched Graft

Asian Cardiovascular and Thoracic Annals ◽

10.1177/021849230201000408 ◽

2002 ◽

Vol 10 (4) ◽

pp. 318-321 ◽

Cited By ~ 3

Author(s):

Hiroyuki Tsukui ◽

Shigeyuki Aomi ◽

Hideyuki Tomioka ◽

Masaki Nonoyama ◽

Hitoshi Koyanagi ◽

...

Keyword(s):

Aortic Arch ◽

Superior Vena Cava ◽

Cerebral Perfusion ◽

Superior Vena ◽

Vena Cava ◽

Conventional Technique ◽

Retrograde Cerebral Perfusion ◽

Neurologic Dysfunction ◽

Group A ◽

Group B

To compare the arch-first technique with conventional aortic arch reconstruction 19 patients were randomly assigned to either procedure. Nine patients underwent the arch-first technique (group A) and 10 underwent the conventional technique (group B). There were no hospital deaths and no significant differences between groups in terms of intraoperative bleeding or the duration of operation cardiopulmonary bypass aortic crossclamping recovery from anesthesia or intensive care. The mean duration of retrograde cerebral perfusion via the superior vena cava was significantly shorter in group A (41.7 ± 10.4 min) than group B (63.9 ± 10 min). Transient neurologic dysfunction was noted in 4 (44%) patients in group A 6 (60%) in group B postoperatively but there was no permanent neurologic dysfunction in either group. The arch-first technique makes it possible to reduce the duration of cerebral ischemia retrograde cerebral perfusion via the superior vena cava reestablish antegrade cerebral perfusion earlier without damaging severely atheromatous arch vessels or conducting retrograde cerebral perfusion via a femoral artery. This technique has the potential to reduce the incidence of neurologic dysfunction.

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