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Eur J Cardiothorac Surg 2001;19:765-770
© 2001 Elsevier Science NL

Antegrade selective cerebral perfusion during surgery of the thoracic aorta: risk analysis

Roberto Di Bartolomeo, Marco Di Eusanio, Davide Pacini, Marco Pagliaro, Carlo Savini, Andrea Nocchi, Angelo Pierangeli

Department of Cardiac Surgery, University of Bologna, Bologna, Italy

Received 30 October 2000; received in revised form 2 April 2001; accepted 2 April 2001.

Corresponding author. Tel.: +39-51-6363361; fax: + 39-51-345990
e-mail: apierangeli{at}orsola-malpighi.med.unibo.it


   Abstract
Top
 Abstract
1. Introduction
 2. Materials and methods
 3. Results
 4. Comment
 References
 
Objective: To determine independent predictors of neurologic outcome and hospital mortality after surgery of the thoracic aorta using moderate hypothermic circulatory arrest and antegrade selective cerebral perfusion. Methods: Between November 1996 and June 2000, 96 consecutive patients (69 men, 27 women; mean age 63±10 years) underwent operations on the thoracic aorta with the aid of moderate hypothermic circulatory arrest and antegrade selective cerebral perfusion. Sixty-four patients were operated on electively (66.7%), 32 emergently (33.3%). Indications for surgery were: type A acute dissection in 30 patients (31.3%), chronic aneurysm in 66 (68.8%). Seventeen patients (17.7%) had undergone previous aortic/cardiac surgical procedures. The mean selective cerebral perfusion time was 52.2±31.9 min (range, 18–220 min). Preoperative, intraoperative, and postoperative factors were analyzed by univariate and multivariate analysis to identify predictors of hospital mortality and neurologic outcome. Results: There were no operative deaths; the hospital mortality rate was 11.5% (11/96). Stepwise logistic regression revealed preoperative renal dysfunction (P=0.021), type A acute dissection (P=0.053), coronary artery bypass grafting (P=0.058), post-operative pulmonary complications (P=0.000) and repeat thoracotomy for bleeding (P=0.027) as independent predictors of hospital mortality. One patient sustained a permanent neurologic deficit (1%). Transient neurologic deficit occurred in eight patients (8.3%). Coronary artery bypass grafting (P=0.013), and postoperative cardiac complications (P=0.049) were statistically associated with an increased risk of any (transient and permanent) neurologic dysfunction on univariate analysis. Stepwise logistic regression indicated coronary artery bypass grafting as independent factor for any neurologic dysfunction. Conclusion: This study confirmed that selective cerebral perfusion is an effective method of cerebral protection allowing complex thoracic aorta operations to be performed with low risk of hospital mortality and adverse neurologic outcome. We didn't find that the duration of selective cerebral perfusion time influence hospital mortality and any neurologic deficit.

Key Words: Antegrade selective cerebral perfusion • Thoracic aorta • Hospital mortality • Neurologic outcome


   1. Introduction
Top
 Abstract
 1. Introduction
2. Materials and methods
 3. Results
 4. Comment
 References
 
The surgical treatment of aneurysms or dissections involving the thoracic aorta still remains one of the most complicated tactical challenges in cardiac surgery where cerebral protection is the primary concern. Various techniques including deep hypothermia with circulatory arrest (DHCA), retrograde cerebral perfusion (RCP) through the superior vena cava, and antegrade selective cerebral perfusion (SCP) have been introduced as means to protect the central nervous system from ischemic damages during the period of arch exclusion.

All three methods have both advantages and disadvantages. DHCA is technically less complicated and provides a still, bloodless operative field. However, there is a limited ‘safe’ time of circulatory arrest and a prolonged cardio-pulmonary bypass (CPB) time is required to cool down and re-warm the patient resulting in a number of pulmonary, renal, cardiac, endothelial dysfunctions as well as an increased microembolism production [1–5]. Coagulative complications are associated with deeper levels of hypothermia. RCP [6,7], introduced to flash out potential embolic air or debris, prolongs the ‘safe’ cerebral time and improves the cerebral cooling. Arch vessels manipulation can be avoided with this technique. However, all the complications associated with deep hypothermia and prolonged CPB time are not avoided and there may be a reduced surgical visibility because of the blood return to the arch vessels. SCP prolongs the ‘safe’ time of circulatory arrest, improves the cerebral cooling, may be used with moderate hypothermia and also provides a technical flexibility with an independent control of systemic and cerebral perfusion being possible [8,9]. Arch vessels manipulation and cannulation as well as technical complexity and reduced surgical visibility are reported as drawbacks of this technique.

In 1996, we begun using SCP with moderate hypothermia as a method of cerebral protection during surgery of the aortic arch. Our experience has been described before [10]. Here we present an update on our continuing experience with 96 consecutive patients. The aim of the present study is to determine the independent predictors of hospital mortality and neurologic outcome in patients who underwent surgery of the aortic arch with the aid of moderate hypothermic circulatory arrest and SCP.


   2. Materials and methods
Top
 Abstract
 1. Introduction
 2. Materials and methods
3. Results
 4. Comment
 References
 
2.1. Patients’ profile
From November 1996 to June 2000, 96 consecutive patients underwent surgical treatment of aortic disease involving the aortic arch. The records of all patients were examined retrospectively. There were 69 men (71.9%) and 27 women (28.1%) having a mean age of 63 years±10.9 (±standard deviation) (range, 32–79 years). Thirty patients (31.3%) were operated on for type A acute dissection, 16 (16.7%) for chronic post-dissection aneurysm and 50 (52.1%) for degenerative aneurysm. Sixty-four patients (66.7%) were operated on electively, 32 (33.3%) underwent emergent operations (30 patients sustained acute dissection and two impending aneurismal rupture). Associated diseases included hypertension in 54 patients (56.3%), chronic obstructive pulmonary disease in 20 (20.8%), chronic renal dysfunction (defined as a creatinine serum level exceeding 2 mg/dl) in seven (7.3%), coronary artery disease in 21 (21.9%) and diabetes in five (5.2%). Thirty-three patients were smokers (34.4%). Ten patients (10.4%) had a history of previous central neurological deficit (eight transient ischemic attack and two stroke). Seventeen patients (17.7%) had undergone previous aortic/cardiac surgical procedures. Preoperative evaluation of cerebral circulation was performed with Doppler echocardiography, digital angiography, or both in all patients undergoing elective procedures. None of our patients had severe intra or extracranial carotid disease that required surgical correction.

2.2. Operative technique
Median sternotomy was used in 91 patients (94.7%) and median sternotomy plus left antero-lateral thoracotomy in five (5.3%). Details of our cannulation technique and method of SCP with moderate circulatory arrest have been described previously [10]. Briefly, after the patients were heparinized, cannulated and cooled on CPB to 22–26°C of nasopharyngeal temperature using a centrifugal pump (Biomedicus, Medtronic, Inc., Eden Prairie, MN), systemic circulation was arrested and the aorta opened. With the patient in Trendelemburg position, 15 F retrograde coronary sinus cannulas (Chase Medical Inc, Houston, TX), connected with the oxigenator with a separate single-roller pump head, were inserted into the innominate and left common carotid arteries through the aortic lumen. During cannulation, while keeping the arch vessels occluded, perfusion was continued in order to avoid air embolism. After the cannulas were properly placed, the balloon at the tip of the cannulas was manually inflated and held by an encircling tape to prevent displacement except in the case where acute dissection involved the arch vessels. The left subclavian artery was clamped or occluded with a Fogarty catheter (IFM, Clearwater, FL) in order to avoid the steal phenomenon.

The cerebral perfusion was started at rate of 10 ml/min per kg and adjusted to maintain a right radial pressure between 40 and 70 mm of Hg.

During open distal aortic anastomosis [8], blood perfusion to the lower half of the body from the femoral artery was arrested or reduced to 500 ml/min.

Graft replacement was performed for aortic reconstruction in all cases. The extent of aortic replacement was as follows: ascending aorta and hemiarch replacement in 43 patients (44.8%), ascending aorta and total arch replacement in 31 patients (32.3%), total arch replacement in 16 patients (16.7%), total arch and descending aorta replacement in three patients (3.1%). A complete thoracic aorta replacement (ascending aorta, aortic arch and descending aorta) was performed in three patients (3.1%). The elephant trunk technique was performed in seven patients (7.3%). En bloc [11] or separated graft techniques were used to re-implant the arch vessels in case of complete aortic arch replacement. If acute dissection was present, the dissected aortic layers and two Teflon felt were sandwiched together with a monofilament suture. Concomitant procedures included aortic valve replacement in 32 patients (33.3%), modified Bentall procedure in 22 patients (22.9%), coronary artery bypass grafting in 12 patients (12.5%).

2.3. Cardiopulmonary bypass data
The mean CPB time was 175.5±52.1 min (range from 85 to 430 min), and the mean aortic cross-clamp time was 108.8±37.2 min (range from 37 to 213 min). Complete circulatory arrest time, defined as the time between the systemic circulation suspension and the beginning of SCP, ranged from 1 to 11 min, mean 4±1.9 min. The mean SCP time was 52.2±31.9 min (range from 18 to 220 min): 41 patients (42.7%) had a SCP time longer than 45 min and, of them, 29 patients (30.2%) longer than 60 min.

2.4. Statistical analysis
Statistical analysis was performed using SPSS 7.0 statistical software (SPSS Inc, Chicago, IL). Continuos variables were expressed as the mean±one standard deviation, and categorical variables as percentages. All variables were first analyzed using univariate analysis (Mann–Whitney test, {chi}2 test or Fisher's exact test when appropriate) to determine weather any single factor influenced hospital mortality and any (transient and permanent) neurologic dysfunction. A P value of less than 0.05 was taken to indicate statistical significance. Variables that achieved P<0.2 in the univariate analysis were examined using multivariate analysis by forward stepwise logistic regression to evaluate independent risk factors for hospital mortality and for any neurological outcome.


   3. Results
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
4. Comment
 References
 
3.1. In-hospital mortality
There were no operative deaths. Eleven patients died during hospitalization; the hospital mortality rate was 11.5%. Of 11 patients, five were operated on for type A acute dissection, two for impending aneurysmal rupture, and four for true aneurysm. Additionally, two of those patients underwent a previous coronary artery bypass grafting operation. The hospital mortality for elective surgery was 4/64 (6.2%), and it was 7/32 (21.8%) for emergency surgery. Modes of death were multi organ failure (n=8), septic shock (n=1), acute myocardial infarction (n=1), bleeding (n=1).

On univariate analysis, the following factors had a significant influence on hospital mortality: emergent status (P=0.038), post-operative renal failure (P=0.000), post-operative pulmonary failure (P=0.000) and repeat thoracotomy for bleeding (P=0.005) (Table 1). Multivariate analysis revealed preoperative renal dysfunction (OR=5.3; P=0.021), type A acute dissection (OR=3.7; P=0.053), coronary artery bypass grafting (OR=3.5; P=0.058), post-operative pulmonary complications (OR=11.3; P=0.0001), repeat thoracotomy for bleeding (OR=4.8; P=0.027) to be independent predictors of hospital-mortality (Table 2). The extent of aortic replacement and SCP duration were not correlated with hospital mortality.


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  		Table 1. Univariate analysis of hospital mortality and adverse neurologic outcomea.

 

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  		Table 2. Multivariate analysis for significant determinants of hospital mortalitya

 
3.2. In-Hospital morbidity
A stroke occurred post-operatively in 1 of 96 patients (1.0%). That patient was a 62 year old man operated on, electively, for an atherosclerotic aneurysm involving the ascending aorta and the proximal portion of the aortic arch. Thus an ascending aorta and hemiarch replacement was performed. The SCP time was 29 min. He never regained consciousness after surgery, and a computed tomographic scan showed multiple cerebral infarctions. We suppose the stroke was due to an inadequate de-airing of the tubes. Patients who died during hospitalization didn't suffer from cerebral complications.

Transient neurologic dysfunction, defined as post-operative agitation, lethargy or confusion with negative tomographic scanning and complete resolution before discharge occurred in eight patients (8.3%).

Coronary artery bypass grafting (CABG) (P=0.013), and postoperative cardiac complications (P=0.049) were statistically associated with an increased risk of any neurologic dysfunction on univariate analysis (Table 1). Stepwise logistic regression indicated CABG (P=0.007) as independent predictor of any neurologic dysfunction (Table 3).


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  		Table 3. Multivariate analysis for significant determinants of any neurologic deficit

 
Other post-operative complications were bleeding requiring a repeat thoracotomy in eight patients (8.3%), pulmonary complications requiring a mechanical ventilatory support longer than 48 h in 11 patients (11.5%), and renal failure requiring temporary haemodialysis in 11 patients (11.5%). Cardiac complications (17/96; 17.7%) included: acute myocardial infarction (n = 3), cardiac tamponade (n=2), congestive heart failure (n=1), heart block requiring a pace-maker implantation (n=1), left bundle-branch block (n=1), atrial fibrillation (n=11).


   4. Comment
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Comment
References
 
Brain and spinal cord protection from ischemic and embolic injury, avoidance of coagulopathy and haemorrhage, and prevention of myocardial damage during extracorporeal circulation are primary concerns during surgery of the thoracic aorta.

Since the establishment of cardioplegia as a method of protecting the myocardium, a successful operative outcome bases itself on the appropriate selection of cerebral protection techniques.

Deep hypothermia with circulatory arrest, first used by Pierangeli and co-workers [1,2] in 1974 in a prosthetic replacement of the aortic arch, is the most widely used method. However, ‘safe’ time of circulatory arrest constraints [3,4,12], lengthy perfusion times and deeper levels of hypothermia, have prompted a renewed interest in other cerebral protective techniques. Retrograde cerebral perfusion, first reported in 1980 as a treatment for massive air embolism during CPB [13], was later introduced in association with deep hypothermic circulatory arrest as a method of cerebral protection during surgery of the aortic arch and good results have been reported [6,14]. Advantages of RCP include uniform brain cooling, the capacity of limiting cerebral embolism and flushing of toxic metabolites that accumulate during HCA. Reports of successful outcomes after the use of RCP for periods longer then 60 min are not uncommon [14]. However, all the complications associated with both deep hypothermia and prolonged CPB time are not avoided with this technique; retrograde cerebral perfusion capabilities and protective mechanism remain still controversial [15–18]. We had a very limited experience with RCP with results similar to those obtained with DHCA [19].

In November 1996 we begun using SCP with moderate hypothermic circulatory arrest as described by Kazui and co-workers [11,12] during surgery of the aortic arch. This method is basically free from time limitation with regard to brain protection allowing unhurried and meticulous surgical reconstruction of the aortic arch. In our series the mean SCP time was 52.2 min and 30.2% of the patients required SCP time longer than 60 min for an adequate surgical repair to be performed. In the present study one patient out of 96 (1%) sustained a permanent neurologic complication. This compares favourably with other reports using the same technique of SCP (0 to about 5.4%) [20–24], DHCA (0 to about 11%) [3,4,19], and RCP (0 to about 12.5%) [6,7,14,25]. Transient neurologic dysfunctions (TND) occurred in eight patients for a rate of 8.3%.

The overall in-hospital mortality rate (11.5%) compares favourably with other reports. Kazui and co-workers [24] reported an overall hospital mortality rate of 12.7% in 220 patients undergoing a total arch replacement procedure. Chronic renal failure, long pump time, and shock were independent determinants of in-hospital mortality on multivariate analysis. SCP time did not significantly influenced hospital mortality or neurologic outcome. Dossche and co-authors [22] reported a hospital mortality of 8.6%. In their series SCP had a favourable impact on hospital mortality and neurologic outcome. Bachet and associates [23] reported a hospital mortality of 16.9%; extension of aortic replacement and age greater than 60 years were prominent risk factors while duration of circulatory arrest, CPB and SCP had no significant influence on the hospital outcome. Ueda [14] reported a hospital mortality of 10% in a group of patients where RCP was used as a method of brain protection; RCP time, pump time and age were indicated as risk factors for hospital mortality on multivariate analysis. We found in our series that preoperative renal dysfunction, type A acute dissection, coronary artery bypass grafting, post-operative pulmonary failure, repeat thoracotomy for bleeding were independent predictors of hospital-mortality (Table 2). The extent of aortic replacement and SCP duration were not correlated with hospital mortality.

Both technical complexity and manipulation of the arch vessels in case of acute dissection or in the presence of loose atheroma in the aortic arch are indicated as principle drawbacks of SCP with moderate circulatory arrest. With our growing experience we found very simple to insert the cannulas into the arch vessels; in this series it took a mean time of complete circulatory arrest of 4.1 min. We use 15 F retrograde coronary sinus cannulas; they are made of silicon, flexible and can be placed toward the patient's head not obscuring the operative field. In the case of acute dissection it was always easy to insert the cannula through the aortotomy into the true lumen and in case of a clear involvement of the arch vessels by the acute dissection a 3-branched graft was used. Up to date no complications resulting from cannulation of supraaortic vessels were observed in our experience, or in those of Kazui [24], Dossche [22], Bachet [23].

In conclusion, this study confirmed that selective cerebral perfusion is an effective method of cerebral protection allowing complex thoracic aorta operations to be performed with low risk of hospital mortality and adverse neurologic outcome. We didn't find that the duration of selective cerebral perfusion time influenced hospital mortality and any neurologic deficit.


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

  1. Pierangeli A., Colì G., Mikus P.M. Sostituzione dell'arco aortico in ipotermia profonda per ipotermia. Bull Scienze Med 1974;2:1-16.
  2. Pierangeli A., Colì G., Donati A., Galli R., Mikus P.M., Turinetto B. Treatment of aortic arch aneurysm with deep hypothermia and circulatory arrest. J Cardiovasc Surg 1975;16:409-414.[Medline]
  3. Svensson L.G., Crawford E.S., Hess H.R., Coselli J.S., Raskin S., Shenaq S.A., Safi H.J. Deep hypothermia with circulatory arrest: determinants of stroke and early mortality in 656 patients. J Thorac Cardiovasc Surg 1993;106:19.[Abstract]
  4. Crawford E.S., Svensson L.G., Coselli J.S., Safi H.J., Hess K.R. Surgical treatment of aneurysm and/or dissection of the ascending aorta, transverse aortic arch, and ascending aorta and transverse aortic arch. Factors influencing survival in 717 patients. J Thorac Cardiovasc Surg 1989;98:659-674.[Abstract]
  5. Cooper W.A., Duarte I.G., Thourani V.H., Nakamura M., Wang N.P., Brown W.M., Gott J.P., Vinten-Johansen J., Guyton R.A. Hypothermic circulatory arrest causes multisystem vascular endothelial dysfunction and apoptosis. Ann Thorac Surg 2000;69:696-703.[Abstract/Free Full Text]
  6. Ueda Y., Miki S., Kusuhra K., Okita Y., Tahata T., Yamanaka K. Surgical treatment of aneurysm or dissection involving the ascending aorta and aortic arch, utilizing circulatory arrest and retrograde cerebral perfusion. J Cardiovasc Surg 1990;31:553-558.[Medline]
  7. Safi H.J., Brien H.W., Winter J.N., Thomas A.C., Maulsby R.L., Doerr H.K., Svensson L.G. Brain protection via retrograde perfusion during aortic arch aneurysm repair. Ann Thorac Surg 1993;56:170-176.[Abstract]
  8. Kazui T., Inoue N., Ymada O., Komatsui S. Selective cerebral perfusion during operation for aneurysms of aortic arch. A reassessment. Ann Thorac Surg 1992;53:109-114.[Abstract]
  9. Kazui T., Kimura N., Komatsu S. Surgical treatment of aortic arch aneurysms using selective cerebral perfusion: experience with 100 patients. Eur J Cardio-thorac Surg 1995;9:491-495.[Abstract]
  10. Di Bartolomeo R., Pacini D., Di Eusanio M., Pierangeli A. Antegrade selective cerebral perfusion during operations on the thoracic aorta: our experience. Ann Thorac Surg 2000;70:10-16.[Abstract/Free Full Text]
  11. Pearce C.W., Weichert R.F., Real R.E. Aneurysms of aortic arch. Simplified technique for excision and prosthetic replacement. J Thorac Cardiovasc Surg; 1969;58:886-890.[Medline]
  12. Mc Cullogh J.N., Zhang N., Reich D.L., Juvonen T.S., Klein J.J., Spielvogel D., Ergin M.A., Griepp R.B. Cerebral metabolic suppression during hypothermic circulatory arrest in humans. Ann Thorac Surg 1999;67:1895-1899.[Abstract/Free Full Text]
  13. Mills N.L., Ochsner J.L. Massive air embolism during cardioplulmonary bypass: causes, prevention, and management. J Thorac Cardiovasc Surg 1982;83:249-255.[Abstract]
  14. Ueda Y., Okita Y., Aomi S., Koyonagi H., Takamoto S. Retrograde cerebral perfusion for aortic arch surgery: analysis of risk factors. Ann Thoac Surg 1999;67:1879-1882.
  15. Dresser L., McKinney W. Anatomic and phatophysiologic studies of the human internal jugular valves. Am J Surg 1987;154:220-224.[Medline]
  16. De Brux J.L., Subavi J.B., Pegis J.D., Pillet J. Retrograde cerebral perfusion: anatomic study of the distribution of blood to the brain. Ann Thorac Surg 1995;60:1294-1298.[Abstract/Free Full Text]
  17. Sakurada T., Kazui T., Tanaka H., Komatsui S. Comparative experimental study of cerebral protection during aortic arch reconstruction. Ann Thorac Surg 1996;61:1348-1354.[Abstract/Free Full Text]
  18. Pagano D., Boivin C., Faroqui M.H., Bonser R.S. Retrograde cerebral perfusion through the superior vena cava perfuses the brain in human being. J Thorac Cardiovasc Surg 1996;111:270-272.[Free Full Text]
  19. Di Bartolomeo R, Giancola R., Pacini D., Longo M., Farneti P.A., Fiorani V., Pierangeli A. Trattamento degli aneurismi dell'arco aortico in ipotermia profonda e arresto cardiocircolatorio. Minerva Chir 1997;52:89-94.
  20. Bachet J., Guilmet D., Goudon B., Termignon J.L., Teodori G., Dreyfus G., Brodaty D., Dubois C., Delentdecker P. Cold cerebroplegia. A new technique of cerebral protection during operations on the transverse aortic arch. J Thorac Cardiovasc Surg 1991;102:85-94.[Abstract]
  21. Veeragandham R., Hamilton I.N., O'Connor C., Rizzo V., Najafi H. Experience with antegrade bihemispheric cerebral perfusion in aortic arch operations. Ann Thorac Surg 1998;66:493-499.[Abstract/Free Full Text]
  22. Dossche K., Morshuis W., Schepens M., Waanders F.G. Bilateral antegrade selective cerebral perfusion during surgery on the proximal thoracic aorta. Eur J Cardio-thorac Surg 2000;17:462-467.[Abstract/Free Full Text]
  23. Bachet J., Guilmet D., Goudot B., Dreyfus G.D., Delentdecker P., Brodaty D., Dubois C. Antegrade cerebral perfusion with cold blood: a 13-year experience. Ann Thorac Surg 1999;67:1874-1878.[Abstract/Free Full Text]
  24. Kazui T., Washiyama N., Bashar A.H., Terada H., Yamashita K., Takinami M., Tamiya Y. Total arch replacement using aortic arch branched grafts with the aid of antegrade selective cerebral perfusion. Ann Thorac Surg 2000;70:3-9.[Abstract/Free Full Text]
  25. Coselli J.S., Büket S., Djukanovic B. Aortic arch operation: current treatment and results. Ann Thorac Surg 1995;59:19-27.[Abstract/Free Full Text]



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