Retrograde inferior vena caval perfusion for total aortic arch replacement surgery: a randomized pilot study

Abstract Objectives Antegrade cerebral perfusion (ACP) under moderate hypothermic circulatory arrest is used during total aortic arch replacement surgery (TARS) in patients with acute type A aortic dissection, but it is associated with high mortality and morbidity. We hypothesized that combining ACP with retrograde inferior vena caval perfusion (RIVP) improves outcomes. Methods This pilot study was prospective, randomized, controlled and assessor-blinded. Patients scheduled for TARS were randomly treated with either ACP or RIVP + ACP. The primary outcome was a composite of mortality and major complications including paraplegia, postoperative renal failure, severe liver dysfunction, and gastrointestinal complications. Secondary outcomes included neurological complications, length of intubation and requirement of blood products. Results A total of 76 patients were recruited (n = 38 per group). Primary outcome occurred in 23 patients (61%) in the ACP group and 16 (42%) in the RIVP + ACP group (OR: 0.60, 95% CI: 0.21–1.62; p = 0.31). There was a lower incidence of transient neurological deficits in the RIVP + ACP group (26% vs. 58%, OR: 0.26; 95% CI: 0.10–0.67,p = 0.006;). The RIVP + ACP group underwent shorter intubation (25 vs 47 h, p = 0.022) and required fewer blood products (red cells, 3.8 units vs 6.5 units, p = 0.047; platelet: 2.0 units vs 2.0 units, p = 0.023) compared with the ACP group. Conclusions RIVP + ACP may be associated with lower incidence of transient neurological deficits, shorter intubation and less blood transfusion requirement than ACP alone during TARS. Multi-center, randomized trials with larger samples are required to determine whether RIVP + ACP is associated with lower rates of mortality and major complications. Trial registration: Pilot study of a RCT registered in clinicaltrials.gov (NCT03607786), Registered 30 July, 2018—Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03607786.

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Retrograde inferior vena caval perfusion for total aortic arch replacement surgery: a randomized pilot study

10.21203/rs.3.rs-39114/v1 ◽

2020 ◽

Author(s):

Jing Lin ◽

Xinhao Liu ◽

Jiyue Xiong ◽

Zhong Wu ◽

Yingqiang Guo ◽

...

Keyword(s):

Pilot Study ◽

Aortic Arch ◽

Lower Incidence ◽

Primary Outcome ◽

Inferior Vena ◽

Neurological Deficits ◽

Aortic Arch Replacement ◽

Inferior Vena Caval ◽

Replacement Surgery ◽

Total Aortic Arch Replacement

Abstract OBJECTIVESAntegrade cerebral perfusion (ACP) under moderate hypothermic circulatory arrest is used during total aortic arch replacement surgery (TARS) in patients with acute type A aortic dissection, but it is associated with high mortality and morbidity. We hypothesized that combining ACP with retrograde inferior vena caval perfusion (RIVP) improves outcomes.METHODSThis pilot study was prospective, randomized, controlled and assessor-blinded. Patients scheduled for TARS were randomly treated with either ACP or RIVP + ACP. The primary outcome was a composite of mortality and major complications including paraplegia, postoperative renal failure, severe liver dysfunction, and gastrointestinal complications. Secondary outcomes included neurological complications, length of intubation and requirement of blood products.RESULTSA total of 76 patients were recruited (n = 38 per group). Primary outcome occurred in 23 patients (61%) in the ACP group and 16 (42%) in the RIVP + ACP group (OR: 0.60, 95% CI: 0.21–1.62; p = 0.31). There was a lower incidence of transient neurological deficits in the RIVP + ACP group (26% vs. 58%, p = 0.006; OR: 0.26; 95% CI: 0.10–0.67). The RIVP + ACP group underwent shorter intubation (25 vs 47 h, p = 0.022) and required fewer blood products (red cells, 3.8 units vs 6.5 units, p = 0.047; platelet: 2.0 units vs 2.0 units, p = 0.023) compared with the ACP group.CONCLUSIONSRIVP + ACP may be associated with lower incidence of transient neurological deficits, shorter intubation and less blood transfusion requirement than ACP alone during TARS. Multi-center, randomized trials with larger samples are required to determine whether RIVP + ACP is associated with lower rates of mortality and major complications.Trial registrationPilot study of a RCT registered in clinicaltrials.gov (NCT03607786)，Registered 30 July, 2018- Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03607786.

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Retrograde Inferior Vena Caval Perfusion for Total Aortic Arch Replacement Surgery (RIVP-TARS): A Multicenter, Randomized, Controlled, Double-Blind Trial

10.21203/rs.2.94/v1 ◽

2018 ◽

Author(s):

Jing Lin ◽

Zhaoxia Tan ◽

Xiaolin Hu ◽

Hao Yao ◽

Dafa Zhang ◽

...

Keyword(s):

Inferior Vena ◽

Moderate Hypothermia ◽

Acute Type ◽

Lower Body ◽

Aortic Arch Replacement ◽

Inferior Vena Caval ◽

Type A Aortic Dissection ◽

Replacement Surgery ◽

Randomized Controlled ◽

Total Aortic Arch Replacement

Abstract Background: During total aortic arch replacement surgery (TARS) for patients with acute type A aortic dissection, organs in the lower body such as the viscera and spinal cord are at risk of ischemia even when antegrade cerebral perfusion (ACP) is performed. Combining ACP with retrograde inferior vena caval perfusion (RIVP) during TARS may improve outcomes by providing the lower body with oxygenated blood. Methods: This is a multi-center, randomized, controlled trial of 500 patients scheduled for TARS. Patients were randomly allocated to a moderate hypothermia circulatory arrest (MHCA) group, who received selective ACP with moderate hypothermia during TARS; or to an RIVP group, who received the combination of RIVP and selective ACP under moderate hypothermia during TARS. The primary outcome was a composite of early mortality and major complications, including paraplegia, postoperative renal failure, severe liver dysfunction, postoperative prolonged intubation (>48 h), and gastrointestinal complications. Discussion: This study aims to assess whether RIVP combined with selective ACP leads to superior outcomes than selective ACP alone for patients undergoing TARS under moderate hypothermia. This study seeks to provide high-quality evidence for RIVP to be used in patients with acute type A aortic dissection undergoing TARS.

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Retrograde Inferior Vena caval Perfusion for Total Aortic arch Replacement Surgery (RIVP-TARS): study protocol for a multicenter, randomized controlled trial

Trials ◽

10.1186/s13063-019-3319-2 ◽

2019 ◽

Vol 20 (1) ◽

Cited By ~ 1

Author(s):

Jing Lin ◽

Zhaoxia Tan ◽

Hao Yao ◽

Xiaolin Hu ◽

Dafa Zhang ◽

...

Keyword(s):

Randomized Controlled Trial ◽

Aortic Arch ◽

Inferior Vena ◽

Controlled Trial ◽

Aortic Arch Replacement ◽

Inferior Vena Caval ◽

Replacement Surgery ◽

Randomized Controlled ◽

Total Aortic Arch Replacement ◽

Multicenter Randomized Controlled Trial

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Retrograde inferior vena caval perfusion for total aortic arch replacement surgery (RIVP-TARS): study protocol for a multicenter, randomized, controlled trial

10.21203/rs.2.94/v2 ◽

2019 ◽

Author(s):

Jing Lin ◽

Zhaoxia Tan ◽

Hao Yao ◽

Xiaolin Hu ◽

Dafa Zhang ◽

...

Keyword(s):

Inferior Vena ◽

Moderate Hypothermia ◽

Acute Type ◽

Lower Body ◽

Aortic Arch Replacement ◽

Inferior Vena Caval ◽

Type A Aortic Dissection ◽

Replacement Surgery ◽

Randomized Controlled ◽

Total Aortic Arch Replacement

Abstract Background: During total aortic arch replacement surgery (TARS) for patients with acute type A aortic dissection, organs in the lower body such as the viscera and spinal cord are at risk of ischemia even when antegrade cerebral perfusion (ACP) is performed. Combining ACP with retrograde inferior vena caval perfusion (RIVP) during TARS may improve outcomes by providing the lower body with oxygenated blood. Methods: This study is designed as a multicenter, computer-generated randomized, controlled, assessor-blind, parallel-group study with a superiority framework in patients scheduled for TARS.A total of 636 patients will be randomized on a 1:1 basis to a moderate hypothermia circulatory arrest (MHCA) group, who will receive selective ACP with moderate hypothermia during TARS; or to an RIVP group, who will receive the combination of RIVP and selective ACP under moderate hypothermia during TARS. The primary outcome will be a composite of early mortality and major complications, including paraplegia, postoperative renal failure, severe liver dysfunction and gastrointestinal complications. All patients will be analyzed according to the intention- to-treat protocol. Discussion: This study aims to assess whether RIVP combined with ACP leads to superior outcomes than ACP alone for patients undergoing TARS under moderate hypothermia. This study seeks to provide high-quality evidence for RIVP to be used in patients with acute type A aortic dissection undergoing TARS. Trial registration. Clinicaltrials.gov, NCT03607786. Registered on 30 July 2018.

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Clinical and biochemical outcomes for additive mesenteric and lower body perfusion during hypothermic circulatory arrest for complex total aortic arch replacement surgery

Perfusion ◽

10.1177/0267659112453753 ◽

2012 ◽

Vol 27 (6) ◽

pp. 493-501 ◽

Cited By ~ 10

Author(s):

P Fernandes ◽

A Cleland ◽

C Adams ◽

MWA Chu

Keyword(s):

Aortic Arch ◽

Circulatory Arrest ◽

Hypothermic Circulatory Arrest ◽

Lower Body ◽

Aortic Arch Replacement ◽

Replacement Surgery ◽

Total Aortic Arch Replacement

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Total aortic arch replacement surgery with a Core temperature of 34 °C

Journal of Cardiothoracic Surgery ◽

10.1186/s13019-019-1001-0 ◽

2019 ◽

Vol 14 (1) ◽

Cited By ~ 2

Author(s):

Quan Li ◽

Hong Qu ◽

Tianqi Liu ◽

Jianmin Yu ◽

Meng Lv

Keyword(s):

Aortic Dissection ◽

Aortic Arch ◽

Core Temperature ◽

Circulatory Arrest ◽

Surgical Techniques ◽

Neurological Complications ◽

Aortic Arch Replacement ◽

Replacement Surgery ◽

Total Aortic Arch Replacement ◽

Aortic Replacement

Abstract Background Traditional aortic arch replacement surgery must be performed under moderate or deep hypothermia (22–28 °C) and circulatory arrest. Hypothermia and hypoperfusion can cause damage to the nervous system; therefore, postoperative brain and spinal cord complications are common. Improvements in surgical techniques are necessary to solve this problem. Herein, we report a method of total aortic arch replacement that can be performed at a core temperature of 34 °C, similar to other simple cardiac operations. Case presentation Four patients underwent surgery with this technique (3 males and 1 female, aged 48 to 67 years). Computed tomography angiography performed at admission showed a total aortic dissection, resulting in a diagnosis of Stanford type A aortic dissection. The patients underwent emergency aortic sinus remodelling, ascending aortic replacement, modified aortic arch replacement, and elephant trunk stenting. No patients had neurological complications. During a follow-up of more than 1-month, no patients had aortic valve regurgitation or anastomotic leak. Conclusions This technique can increase the operating temperature by approximately 6 to 12 °C and reduce the circulatory arrest time by approximately 18 to 28 min. All of the patients recovered well without any neurological complications, demonstrating the feasibility and safety of this technique. We believe that this technique can serve as a good alternative strategy for managing aortic dissection and aneurysm, especially for young surgeons who are acquiring experience in arch replacement surgery.

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