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Eur J Cardiothorac Surg 2001;19:594-600
© 2001 Elsevier Science NL

Retrograde cerebral perfusion during thoracic aortic surgery and late neuropsychological dysfunction

David L. Reicha, Suzan Uysala, M. Arisan Erginb, Carol A. Bodianc,1,1, Sabera Hossainc,1,1, Randall B. Grieppb

a Department of Anesthesiology, Mount Sinai School of Medicine, New York, NY 10029, USA
b Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, NY 10029, USA
c Department of Biomathematical Sciences, Mount Sinai School of Medicine, New York, NY 10029, USA

Received 2 October 2000; received in revised form 20 February 2001; accepted 22 February 2001.

Corresponding author. Department of Anesthesiology, Box 1010, Mount Sinai School of Medicine, One Gustave L. Levy Place, New York, NY 10029-6574, USA. Tel.: +1-212-241-7467; fax: +1-212-241-1847
e-mail: david.reich{at}mssm.edu


   Abstract
Top
 Abstract
1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 References
 
Objective: Retrograde cerebral perfusion (RCP) is commonly used in thoracic aortic surgery, ostensibly to provide metabolic support, maintain cerebral hypothermia and/or wash out particulate emboli. We tested the hypothesis that RCP would affect neuropsychological outcome in a clinical cohort. Methods: Ninety-four patients undergoing elective thoracic aortic repairs requiring deep hypothermic circulatory arrest consented to participate in this study. These patients underwent preoperative neuropsychological evaluation and comprise the reference group. Fifty-six of these patients also underwent neuropsychological evaluation several weeks postoperatively, 12 of whom (21%) had RCP. The neuropsychological domains tested were attention, processing speed, memory, executive function, and fine motor function. A global assessment of impairment, negative neuropsychological outcome (NNO), was defined as a postoperative decrease in function in two or more neuropsychological domains for patients with at least three domains tested both pre- and postoperatively (n=48). The relationship of three potential predictors (RCP, cerebral ischemia time and patient age) to negative outcomes was analyzed using Wilcoxon two-sample tests, {chi}2 tests, Mantel–Haenszel tests and multiple logistic regression. P<0.05 was considered significant. Results: Memory dysfunction and NNO had strong associations with RCP. This effect remained significant when controlling separately for age and cerebral ischemia time. Conclusions: The effects of RCP are difficult to distinguish from those of age and prolonged cerebral ischemia time, because complex thoracic aortic repairs are associated with advanced age, prolonged cerebral ischemia and use of RCP. Despite this limitation, these preliminary data indicated that RCP had no beneficial effect (and most likely a negative effect) upon cognitive outcome.

Key Words: Aortic aneurysm, Thoracic • Retrograde cerebral perfusion • Thoracic surgery • Neuropsychology • Outcome study • Hypothermic circulatory arrest


   1. Introduction
Top
 Abstract
 1. Introduction
2. Materials and methods
 3. Results
 4. Discussion
 References
 
Retrograde cerebral perfusion (RCP) is commonly used in thoracic aortic surgery requiring hypothermic circulatory arrest (HCA), ostensibly to improve neurological outcome. There are several potential mechanisms underlying RCP's putative neuroprotective effect in thoracic aortic surgery:

  1. it may flush embolic material from the cerebral circulation [1];
  2. it may provide cerebral flow sufficient to support cellular metabolism [2]; and
  3. it may maintain cerebral hypothermia better than HCA and/or topical cooling [3].
Conversely, RCP causes venous hypertension that may induce injury by means of cerebral edema and increased intracranial pressure [1]. Conflicting results of clinical and animal laboratory studies suggest that none of the proposed mechanisms of cerebral protection or injury noted above are definitively established.

Neuropsychological testing is a sensitive method of measuring subtle neurological injury following surgical interventions, but has not been used to evaluate the effects of RCP. Our group previously reported that HCA >25 min in duration was associated with decreases in memory and fine motor function [4]. In the current investigation, we examined a cohort of patients undergoing surgery requiring HCA with or without RCP in order to determine whether RCP is a predictor of neuropsychological outcome.


   2. Materials and methods
Top
 Abstract
 1. Introduction
 2. Materials and methods
3. Results
 4. Discussion
 References
 
Under an Institution Review Board approved protocol with informed consent, patients undergoing elective thoracic aortic surgery were evaluated with a battery of neuropsychological tests preoperatively (n=94) and at the postoperative outpatient follow-up visit (n=56).

The surgical technique for induction of profound hypothermia and use of circulatory arrest were constant throughout the duration of the study, and have been described in detail previously [5]. Briefly, central cooling on cardiopulmonary bypass was carried out using alpha-stat blood gas management to produce profound total body hypothermia to a core temperature of 12–15°C, as measured in the esophagus. A minimum duration of 30 min is usually required for cooling thorough enough to prevent upward drift of body temperature during prolonged HCA. We used jugular bulb oxyhemoglobin saturation as an indicator of cerebral cooling and concomitant cerebral metabolic suppression. Jugular bulb oxyhemoglobin saturation was monitored every 5 min during the cooling phase prior to HCA, and cooling was continued until saturation exceeded 95% in most cases, or had plateaued above 90%. During HCA, the head was packed in ice to prevent warming of the central nervous system.

RCP was carried out by perfusion of the superior vena caval cannula with arterial blood via an arterial venous limb inserted into the perfusion circuit. Briefly, the venous cannula was perfused with oxygenated blood to a jugular bulb pressure of 15–20 mmHg. No specific flow range limits were imposed. In certain patients, the period of RCP was brief to wash atheroembolic debris from the brachiocephalic vessels. In the remainder, RCP was administered continuously throughout the period during which anterograde flow was interrupted.

Upon reinstitution of anterograde cerebral perfusion and completion of the aortic repair, gradual warming was carried out by means of cardiopulmonary bypass, limiting the gradient between blood and body temperature to less than 10°C, with a maximum blood temperature of 37°C. A warming blanket was also utilized. Central warming was usually discontinued at an esophageal temperature of 35–37°C, and a rectal or bladder temperature of 30–35°C.

All patients were given 30 mg/kg of methylprednisolone prior to HCA. Glucocorticoids were continued in tapering doses for 48 h in those patients with an interval of HCA exceeding 30 min. Recovery occurred in the intensive care unit, and patients were evaluated for gross neurological deficits upon emergence from anesthesia and throughout the intensive care unit stay.

Demographic and perioperative data collected included: age, gender, smoking history, history of hypertension, previous neurological history, aortic atherosclerosis at operation, cardiopulmonary bypass time, minimum esophageal temperature, minimum bladder temperature, myocardial ischemia time, and cerebral ischemia time (defined as the cumulative length of interruption of anterograde cerebral perfusion). Postoperatively, the length of stay in the hospital, the presence of focal neurological deficits, and reasons why postoperative neuropsychological testing could not be completed were recorded.

2.1. Neuropsychological evaluation
All patients underwent neuropsychological evaluations by a psychologist trained in these techniques who was blinded to the clinical aspects of the surgical procedure. In order to assure that patients were not globally impaired to the extent that neuropsychological testing would be invalid, a brief orientation screen was administered (Orientation subtest of the Wechsler Memory Scale – Revised, The Psychological Corporation, San Antonio, TX). No patients were excluded on this basis. The neuropsychological battery consisted of eight tests, with the data consolidated into five domains:

  1. Attention: WAIS-R Digit Span subtest (Wechsler Adult Intelligence Scale – Revised, Psychological Corporation, New York, NY);
  2. Processing Speed: The Trail Making Test, Part A (Halstead–Reitan Neuropsychological Test Battery, Neuropsychology Press, Tucson, AZ) and the Symbol Digit Modalities Test, oral version (Symbol Digit Modalities Test, Western Psychological Services, Los Angeles, CA);
  3. Memory: The Logical Memory subtest (Wechsler Memory Scale – Revised, The Psychological Corporation, San Antonio, TX) and the Verbal Paired Associates subtest (Wechsler Memory Scale – Revised, The Psychological Corporation, San Antonio, TX). Alternate forms of these tests were used for preoperative and postoperative testing to avoid practice effects;
  4. Executive Function: The Trail Making Test, Part B (The Halstead–Reitan Neuropsychological Test Battery, Neuropsychology Press, Tucson, AZ) and the Similarities subtest (Wechsler Adult Intelligence Scale – Revised, Psychological Corporation, New York, NY); and
  5. Fine Motor Function: The Finger Tapping Test (Psychological Assessment Resources, Inc., Odessa, FL) and the Grooved Pegboard Test (Psychological Assessment Resources, Inc., Odessa, FL). The dominant hand was tested.

2.2. Data analysis
Data from all 94 patients were used to establish baseline values for each test and to assess postoperative neurologic deficits. Only those patients who also completed at least one postoperative test were included in the statistical analyses of neuropsychological outcomes.

Demographic and perioperative data were compared between the patients with and without postoperative neuropsychological testing using Wilcoxon two-sample tests for continuous data and {chi}2 tests for binary data. The rates of postoperative neurological deficits for RCP and non-RCP patients were compared using Fisher's Exact test.

The initial step in the neuropsychological data analysis was the consolidation of the raw test data into composite scores for each cognitive domain for each patient at each testing interval. Composite scores were computed by standardizing each neuropsychological test measure in relation to the corresponding mean and standard deviation of the scores of the baseline sample. The total number of patients comprising the baseline sample was 94, but the number completing each individual test varied slightly because some patients did not complete all tests (range 82–94). For each patient in the current study, the standardized score (Z-score) for each test was calculated by subtracting the baseline sample mean from the individual raw test score, and dividing this difference by the baseline sample standard deviation. Composite scores for each patient were defined as the simple numerical average Z-score for all tests (for which data were available) within each cognitive domain. For example, a patient Z-score of +1.0 represents a test score that was one standard deviation above average compared with all patients preoperatively. If a domain consisted of two tests and a patient had a Z-score of 1.0 in one test and 0.5 in the other, then the domain composite score was +0.75 for that patient at that time.

The neuropsychological outcomes were analyzed separately for each domain, first as continuous variables in terms of their composite Z-scores, and then as binary variables, which were defined as positive for the occurrence of neuropsychological deficit if the postoperative Z-score was less than the corresponding preoperative Z-score. In addition, patients with data on three or more domains were classified as experiencing an overall negative neuropsychological outcome (NNO) if they demonstrated a postoperative decrease in composite Z-scores in two or more domains.

The univariate relationship of RCP to the occurrence of deficits in each of the neuropsychological domains and to NNO was analyzed by Wilcoxon two-sample tests for continuous outcomes and {chi}2 tests for binary data. The univariate relationships of age and cerebral ischemia time to deficits in each of the neuropsychological domains and to NNO were analyzed by {chi}2 tests of linear trend, where ages and cerebral ischemia times were each grouped by quartiles.

Since RCP was used more often in older patients and in patients with longer cerebral ischemia times we controlled for age and for time in the tests of association between RCP and the occurrence of neuropsychological deficits. This was done by stratifying the data by quartiles of age and then by quartiles of cerebral ischemia time, and using Mantel–Haenszel tests to compare the risks of neuropsychological deficit in each domain and for NNO within each quartile between the patients who received RCP and those who did not. Additionally, we used multiple logistic regression analyses to check the magnitude and direction of the findings of the Mantel–Haenszel tests, controlling jointly for age and for cerebral ischemia. These were conducted using an exact analysis (LogXact, Cytel Corp., Cambridge MA).


   3. Results
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
4. Discussion
 References
 
Our baseline cohort consisted of 94 patients who underwent preoperative neuropsychological testing, 25 of whom had RCP during surgery. Fifty-six of the original 94 patients had at least one postoperative neuropsychological domain tested at their follow-up outpatient visit, including 12 who had RCP. Seven of these RCP patients had brief retrograde perfusion and five had retrograde perfusion lasting the full period of anterograde flow interruption. Forty-eight patients had at least three domains tested at both testing intervals, including 11 RCP patients. The postoperative follow-up visit occurred at a median of 62 days postoperatively (range 16–121 days).

Demographic and perioperative data comparing patients with postoperative neuropsychological data with patients lost to follow-up are summarized in Table 1. Patients lost to follow-up had higher rates of hypertension (P=0.042), aortic atherosclerosis (P=0.035), and longer cerebral ischemia times (P=0.004). It should also be noted that there were non-significant trends for these patients to be older and have more tobacco use. Overall, the patients who had complete neuropsychological data seem to be a slightly healthier subset.


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  		Table 1. Demographics and perioperative data for patients with postoperative neuropsychological testing and those lost to follow-upa

 
The relation between RCP and postoperative neurological deficit was examined in the 94 patients comprising the baseline sample. Four of 25 RCP patients (16%) versus one of 69 non-RCP patients (1.5%) developed a postoperative neurological deficit (P=0.017). Three RCP patients with postoperative neurological deficits completed postoperative neuropsychological testing at their outpatient visit, which occurred between 99 and 104 days following surgery. None were disoriented but all three of these patients demonstrated NNO.

The association of neuropsychological outcome and RCP was screened initially in univariate analyses of the continuous neuropsychological data (composite Z-scores). Postoperative decreases were significantly associated with RCP for the domains attention (P=0.0086), memory (P=0.01), and processing speed (P=0.01), but not with fine motor dysfunction (P=0.165) or executive function (P=0.23). These results were mirrored in univariate analyses using binary variables (any postoperative decrease in composite Z-scores). RCP remained significantly associated with deficits in attention (P=0.011), memory (P=0.008), and processing speed (P=0.049), but not with fine motor dysfunction (P=0.091) or executive function (P=0.70). RCP was also a significant univariate predictor of NNO (P=0.002). Given the concordance between the results of univariate analyses for continuous and binary outcome data, the remainder of the analyses address binary outcomes only.

RCP was more likely to be employed in older patients and in procedures with long cerebral ischemia times (Tables 2 and 3). Therefore, the univariate analyses described above may, in part, reflect an association between patient age as well as cerebral ischemia time with neuropsychological dysfunction following HCA, which we noted in previous work [4]. This led us to test the influence of these variables on neuropsychological outcome regardless of RCP in these data. Age was a significant univariate predictor of the occurrence of deficits in memory (P=0.002), fine motor function (P=0.015), and NNO (P=0.005). Cerebral ischemia time was also a significant predictor of NNO (P=0.022), but was a weaker predictor of specific deficits in memory (P=0.06) and fine motor function (P=0.121).


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  		Table 2. Cerebral ischemia time by RCP

 

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  		Table 3. Age by RCP

 
Controlling for cerebral ischemia time, Mantel–Haenszel tests demonstrated strong associations of RCP with deficits in memory (P=0.029) and NNO (P=0.015) (Table 4). These results were similar when controlling for age, with associations between RCP and deficits in memory (P=0.027) and NNO (P=0.006) (Table 5). It should be noted that the higher rate of dysfunction and NNO among RCP patients was consistent across the intervals of increasing age and ischemia time.


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  		Table 4. Proportion of patients with postoperative neuropsychological deficits, controlling for cerebral ischemia time

 

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  		Table 5. Proportion of patients with postoperative neuropsychological deficits, controlling for age

 
In multiple logistic regression models, we entered age and cerebral ischemia time as continuous variables. The effects of RCP on memory dysfunction and NNO were consistent in magnitude and direction with the results reported above, but neither reached statistical significance in the final model that included all three factors (RCP, age, and cerebral ischemia time). Due to the small number of adverse outcomes, these analyses yielded wide confidence intervals and are not reported.


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
References
 
RCP was associated with postoperative neurological deficits and adverse neuropsychological outcome in a small cohort of patients undergoing thoracic aortic surgery. These neuropsychological deficits appear to be independent of the important comorbidity factors of cerebral ischemia time and patient age. The specific domains that may be affected by RCP were memory and fine motor function. This is consistent with current concepts of cerebral vulnerability to ischemic injury in that the hippocampus, basal ganglia and cerebellum are among the most sensitive regions [6], and is also consistent with patterns of neuropathology observed in laboratory studies of HCA and RCP [7]. The other domains (attention, cognitive processing speed, and executive function) did not appear to be specifically affected by RCP, but certain patients had deficits in these domains.

The previous literature regarding RCP does not address neuropsychological outcomes, which are the most sensitive measures of brain function. The existing data addressing gross neurological outcome in humans and behavioral outcomes in animal models are contradictory. In order to illustrate the controversial nature of these data, the following paragraphs review this literature.

4.1. Clinical outcome in thoracic aortic surgery
In some case series, RCP duration was not found to be a predictor of death or neurological morbidity [8–11], whereas in others it was a predictor [12–14]. Clinical outcome studies comparing RCP versus HCA have also yielded mixed results. RCP has been found to be associated with neurological morbidity rates that are either similar to those associated with HCA [15,16] or lower [17,18], especially in older patients [19]. In studies which included selective (anterograde) cerebral perfusion patients, RCP patients had similar outcome in two studies [20,21], and worse outcome in one [22].

4.2. Neurological outcome in laboratory investigations
In a study by Juvonen et al. [1], embolization resulted in poor behavioral recovery with or without RCP, despite the effective washout of embolized microspheres. Even in the absence of embolization, mild and transient behavioral impairment occurred following RCP with inferior vena caval occlusion. In another study, Juvonen et al. [23] reported that behavioral outcome was best in RCP without inferior vena caval occlusion, compared to HCA or RCP with inferior vena caval occlusion. In the report by Midulla et al. [24], RCP and HCA with ice-packing of the head had similar outcomes that were significantly improved compared with HCA without ice-packing of the head. Safi et al. [19] also reported that RCP was better than HCA, but did not study HCA with ice-packing of the head. Yerlioglu et al. [25] reported that RCP and anterograde perfusion resulted in complete behavioral recovery, but that embolization resulted in poorer recovery, especially with RCP of >40 mmHg.

4.3. Limitations of the current study
The decision to use RCP in the clinical cohort that served as our data set was made at the surgeon's discretion. There was, therefore, non-random application of RCP, and variability in the flows, duration, and maximal pressure achieved. Furthermore, RCP was used primarily in older patients and patients with more complex repairs and longer cerebral ischemia times, although our data indicate that the influence of RCP was independent of these factors. The postoperative surgical follow-up visit occurred relatively early in the postoperative period (median of 62 days). This may have been too early for a final outcome measurement in some patients.

This imbalance in the data distribution and the small sample size complicated our attempts to evaluate the effects of RCP on memory dysfunction and NNO, independent of the joint effects of cerebral ischemia time and age. Whereas the Mantel–Haenszel tables demonstrate significant associations between RCP and adverse neuropsychological outcome, controlling for age and cerebral ischemia time separately, the small number of adverse outcomes limited the use of multiple logistic regressions and our ability to determine the independence of the effects of RCP from age and cerebral ischemia time jointly. Nevertheless, results of this analysis suggest an independent and negative influence of RCP on these outcomes.

4.4. Conclusions
Despite the limitations of the current study, the data provide preliminary evidence that RCP does not improve brain function following thoracic aortic surgery and potentially has harmful effects. Considerable uncertainty remains regarding the appropriateness of RCP, as there is controversy regarding its ability to provide cerebral protection and growing evidence that it may be injurious. Specific aspects of the RCP technique that require further investigation include: the optimal temperature, flow, and perfusion pressure; the cannulation method; the duration of perfusion (e.g. brief flush versus continuous flow); and the use of pharmacological adjuncts. Prospective randomized trials will be necessary to resolve these issues.


   Footnotes
 
1 Consulting statisticians. Back


   References
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 References
 

  1. Juvonen T., Weisz D., Wolfe D., Zhang N., Bodian C.A., McCullough J.N., Mezrow C.K., Griepp R.B. Can retrograde perfusion mitigate cerebral injury after particulate embolization? A study in a chronic porcine model. J Thorac Cardiovasc Surg 1998;115:1142-1159.[Abstract/Free Full Text]
  2. Usui A., Hotta T., Hiroura M., Murase M., Maeda M., Koyama T., Tanaka M., Takeuchi E., Yasuura K., Watanabe T., Abe T. Retrograde cerebral perfusion through a superior vena caval cannula protects the brain. Ann Thorac Surg 1992;53:47-53.[Abstract]
  3. Anttila V., Pokela M., Kiviluoma K., Mäkiranta M., Hirvonen J., Juvonen T. Is maintained cranial hypothermia the only factor leading to improved outcome after retrograde cerebral perfusion? An experimental study with a chronic porcine model. J Thorac Cardiovasc Surg 2000;119:1021-1029.[Abstract/Free Full Text]
  4. Reich D.L., Uysal S., Sliwinski M., Ergin M.A., Kahn R.A., Konstadt S.N., McCullough J., Hibbard M.R., Gordon W.A., Griepp R.B. Neuropsychological outcome following deep hypothermic circulatory arrest in adults. J Thorac Cardiovasc Surg 1999;117:156-163.[Abstract/Free Full Text]
  5. Ergin M.A., Galla J.D., Lansman S.L., Quintana C., Bodian C., Griepp R.B. Hypothermic circulatory arrest in operations on the thoracic aorta. J Thorac Cardiovasc Surg 1994;107:788-799.[Abstract/Free Full Text]
  6. Ginsberg M.D., Graham D.I., Busto R. Regional glucose utilization and blood flow following graded forebrain ischemia in the rat: correlation with neuropathology. Ann Neurol 1985;18:470-481.[Medline]
  7. Ye J., Yang L., Del Bigio M.R., Filgueiras C.L., Ede M., Summers R., Salerno T.A., Deslauriers R. Neuronal damage after hypothermic circulatory arrest and retrograde cerebral perfusion in the pig. Ann Thorac Surg 1996;61:1316-1322.[Abstract/Free Full Text]
  8. Deeb G.M., Williams D.M., Quint L.E., Monaghan H.M., Shea M.J. Risk analysis for aortic surgery using hypothermic circulatory arrest with retrograde cerebral perfusion. Ann Thorac Surg 1999;67:1883-1886.[Abstract/Free Full Text]
  9. Murase M., Maeda M., Koyama T., Tomida Y., Murakami F., Teranishi K., Ogawa Y., Seki A., Okamoto H., Hoshino M., Usui A., Abe T. Continuous retrograde cerebral perfusion for protection of the brain during aortic arch surgery. Eur J Cardio-thorac Surg 1993;7:597-600.[Abstract]
  10. Okita Y., Takamoto S., Ando M., Morota T., Matsukawa R., Kawashima Y. Mortality and cerebral outcome in patients who underwent aortic arch operations using deep hypothermic circulatory arrest with retrograde cerebral perfusion: no relation to early death, stroke and delirium to the duration of circulatory arrest. J Thorac Cardiovasc Surg 1998;115:129-138.[Abstract/Free Full Text]
  11. Ueda Y., Miki S., Okita Y., Tahata T., Ogino H., Sakai T., Morioka K., Matsuyama K. Protective effect of continuous retrograde cerebral perfusion on brain during deep hypothermic systemic circulatory arrest. J Card Surg 1994;9:584-595.[Medline]
  12. Wong C.H., Bonser R.S. Does retrograde cerebral perfusion affect risk factors for stroke and mortality after hypothermic circulatory arrest?. Ann Thorac Surg 1999;67:1900-1903.[Abstract/Free Full Text]
  13. Ueda Y., Okita Y., Aomi S., Koyanagi H., Takamoto S. Retrograde cerebral perfusion for aortic arch surgery: analysis of risk factors. Ann Thorac Surg 1999;67:1879-1882.[Abstract/Free Full Text]
  14. Usui A., Abe T., Murase M., Tanaka M., Takeuchi E., Ishihara T., Hoshino M., Ogawa Y., Seki A., Okamoto H., Moriya H. Early experience of retrograde cerebral perfusion. Cardiovasc Surg 1997;5:510-515.[Medline]
  15. Shapira O.M., Aldea G.S., Cutter S.M., Fitzgerald C.A., Lazar H.L., Shemin R.J. Improved clinical outcomes after operation of the proximal aorta: a 10-year experience. Ann Thorac Surg 1999;67:1030-1037.[Abstract/Free Full Text]
  16. Wong C.H., Bonser R.S. Does retrograde cerebral perfusion affect risk factors for stroke and mortality after hypothermic circulatory arrest?. Ann Thorac Surg 1999;67:1900-1903.
  17. Coselli J.S. Retrograde cerebral perfusion is an effective means of neural support during deep hypothermic circulatory arrest. Ann Thorac Surg 1997;64:908-912.
  18. Ehrlich M., Fang C., Grabenwoeger M., Cartes-Zumelzu F., Wolner E., Havel M. Perioperative risk factors for mortality in patients with acute type A aortic dissection. Circulation 1998;98:294-298.[Abstract/Free Full Text]
  19. Safi H.J., Letsou G.V., Iliopoulos D.C., Subramanian M.H., Miller C.C., Hassoun H., Asimacopoulos P.J., Baldwin J.C. Impact of retrograde cerebral perfusion on ascending aortic and arch aneurysm repair. Ann Thorac Surg 1997;63:1601-1607.[Abstract/Free Full Text]
  20. Okita Y., Ando M., Minatoya K., Kitamura S., Takamoto S., Nakajima N. Predictive factors for mortality and cerebral complications in arteriosclerotic aneurysm of the aortic arch. Ann Thorac Surg 1999;67:72-78.[Abstract/Free Full Text]
  21. Usui A., Yasuura K., Watanabe T., Maseki T. Comparative clinical study between retrograde cerebral perfusion and selective cerebral perfusion in surgery for acute type A aortic dissection. Eur J Cardio-thorac Surg 1999;15:571-578.[Abstract/Free Full Text]
  22. Ceriana P., Barzaghi N., Locatelli A., Veronesi R., De Amici D. Aortic arch surgery: retrospective analysis of outcome and neuroprotective strategies. J Cardiothorac Surg 1998;39:337-342.
  23. Juvonen T., Zhang N., Wolfe D., Weisz D.J., Bodian C.A., Shiang H.H., McCullough J.N., Griepp R.B. Retrograde cerebral perfusion enhances cerebral protection during prolonged hypothermic circulatory arrest: a study in a chronic porcine model. Ann Thorac Surg 1998;66:38-50.[Abstract/Free Full Text]
  24. Midulla P.S., Gandsas A., Sadeghi A.M., Mezrow C.K., Yerlioglu M.E., Wang W., Wolfe D., Ergin M.A., Griepp R.B. Comparison of retrograde cerebral perfusion to anterograde cerebral perfusion and hypothermic circulatory arrest in a chronic porcine model. J Card Surg 1994;9:560-575.[Medline]
  25. Yerlioglu M.E., Wolfe D., Mezrow C.K., Weisz D.J., Midulla P.S., Zhang N., Shiang H.H., Bodian C., Griepp R.B. The effect of retrograde cerebral perfusion after particulate embolization to the brain. J Thorac Cardiovasc Surg 1995;110:1470-1485.[Abstract/Free Full Text]



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