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Eur J Cardiothorac Surg 2003;23:771-775
© 2003 Elsevier Science NL

Total arch replacement using antegrade selective cerebral perfusion with right axillary artery perfusion

^a Department of Cardiovascular Surgery, National Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka 565-8565, Japan
^b Department of Thoracic Surgery, Fujita Health University, Nagoya, Japan

Received 30 September 2002; received in revised form 31 January 2003; accepted 4 February 2003.

^* Corresponding author. Tel.: +81-6-6833-5012; fax: +81-6-6872-7486
e-mail: hogino{at}hsp.ncvc.go.jp

	Abstract

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A. Conference... References

 
Objective: Right axillary artery (AxA) perfusion, which can prevent cerebral embolism caused by retrograde perfusion via the femoral artery (FA), was used for selective cerebral perfusion (SCP) as well as cardiopulmonary bypass (CPB) in aortic arch repair. We review the outcome of aortic arch surgery using SCP with right AxA perfusion to clarify its efficacy. Method: Between 1998 and 2002, 120 patients underwent aortic arch repair using SCP with right AxA perfusion. The mean age was 69±10 years. Aneurysms were atherosclerotic in 79, dissecting in 32, and others in nine patients. Twenty of them (16.7%) required emergency surgery. CPB was initiated with right AxA and FA perfusion, and following SCP was established using right AxA and left common carotid artery perfusion. Results: With right AxA perfusion, hospital mortality was 5.8%. Multivariate analysis showed only ruptured aneurysm was an independent determinant for hospital mortality. Permanent neurological dysfunction developed in one patient (0.8%), while seven (5.8%) suffered from temporary one. In univariate analysis, SCP time, stenosis of the carotid arteries, past history of cerebrovascular events, and atherosclerotic aneurysm were not related to temporary neurological deficits Conclusion: Right AxA perfusion in conjunction with SCP is a safe and useful alternative for brain protection in total arch replacement.

Key Words: Aortic arch replacement • Selective cerebral perfusion • Neurological dysfunction • Axillary artery perfusion

	1. Introduction

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A. Conference... References

 
Prevention of cerebral embolic events is one of important clinical subjects during aortic arch surgery. For it, selection of arterial cannulation site for cardiopulmonary bypass (CPB) is crucial. The ascending aorta (asc. Ao) or the femoral artery (FA) is usually chosen as an arterial cannulation site. However, cerebral emboli can occur in cases of both cannulation sites, because of severe atherosclerotic changes of the asc. Ao near the arch aneurysm or retrograde perfusion via the FA. Since 1998 we have employed right axillary artery (AxA) perfusion in aortic arch repair using selective cerebral perfusion (SCP) to reduce the incidence of cerebral emboli. We review the outcome of total arch replacement to confirm the efficacy of right AxA perfusion in conjunction with SCP.

	2. Material and methods

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A. Conference... References

 
2.1. Patient profiles
Between 1998 and 2002, 120 patients underwent total arch replacement using SCP with right AxA perfusion. Patients ranged in age from 17 to 86 years (mean 69±10 years), 99 were men and 21 women. Seventy-nine patients were treated for atherosclerootic aneurysm, 16 for acute aortic dissection, 16 for chronic aortic dissection, and nine for others (pseudoaneurysm, mycotic aneurysm, and aortitis). Associated past history included cerebrovascular disease in 13 (10.8%), coronary artery disease in 21 (17.5%), and aortic disease in 16 (13.3%). Other coexisting diseases were chronic renal failure (serum creatinine >2.0) in 6 (6.0%), carotid artery stenosis (>50% on echo) in 12 (10%), chronic heart failure (fractional shortening <0.3 on echocardiography) in 13 (10.8%), and chronic obstructive pulmonary disease (%FEV1.0 <65%) in 28 (23.3%). Ten (8.3%) patients had shock status preoperatively. Five (4.2%) of them had a ruptured aneurysm.

2.2. Operative techniques
Aneurysms were approached through a median sternotomy in all. The right AxA was exposed for cannulation through a 5–7 cm skin incision at the right armpit. For CPB, a straight cannula in size of 12–16 Fr was inserted into the right AxA, while FA perfusion was also established at the inguinal portion. Bicaval venous drainage was employed. CPB was initially started only with right AxA perfusion, and was completely established with following FA perfusion to prevent embolism caused by retrograde FA perfusion. At 22°C of nasopharyngeal temperature, systemic circulatory arrest was induced. The brachiocephalic and left common carotid arteries were clamped gently, by which antegrade cerebral perfusion through the right AxA was commenced. The arch was opened and the left common carotid artery (LCCA) was cannulated using a 12 Fr balloon tipped cannula. The left subclavian artery (LSCA) was then clamped. Antegrade SCP was established at the rate of 500 ml/min using a single roller pump separate from the systemic circulation. The pressure of the both sides of temporal arteries was monitored, which was controlled between 30 and 50 mmHg by regulating SCP flow. Simultaneously, retrograde and antegrade cold blood cardioplegia was infused.

In this series, knitted or woven Dacron quadrifurcated grafts were used for aortic arch repair, while only one patient with a mycotic aneurysm had aortic allograft repair. Through the aneurysm, the descending aorta distal to the aneurysm was divided from the inside to prevent nerve injury. Open distal anastomosis was done with circulatory arrest of the lower half of body. After the distal anastomosis, debris or air was flushed out from the descending aorta through FA perfusion. The graft was cross-clamped proximally, and antegrade systemic circulation was started from the branch of the main Dacron graft. The LSCA was reconstructed using a branch graft. Rewarming was started. The proximal end of the main graft was anastomosed to the ascending aorta and coronary circulation was started by declamping. The second branch graft was anastomosed to the LCCA and the first branch graft was anastomosed to the brachiocephalic artery respectively. Cannulae of the right AxA and the FA were removed.

An elephant trunk procedure was used at the distal aortic anastomosis site in 33 (27.5%). Concomitant procedures included coronary artery bypass grafting in 15 (12.5%), Bentall type operation in 4 (3%), extended repair to the descending aorta in 6 (5%), abdominal aortic aneurysm repair in 2 (1.6%), heart valve surgery in 3 (2.5%), closure of atrial septal defect in 1 (0.8%), and peripheral vascular operation in 2 (1.6%).

2.3. Statistical methods
The continuous data in this paper are expressed as the mean±standard deviation. All variables were first analyzed using univariate analysis (Fisher's exact test) to determine which factors influenced hospital mortality and neurological dysfunction. Some variables that achieved a p value of less than 0.2 in the univariate analysis were examined using multivariable analysis of a forward stepwise logistic regression model. Survival rate was estimated by a Kaplan–Meier method. All computations were performed using Statview 5.0 (SAS Institute, Cary, NC) statistical software packages.

	3. Results

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A. Conference... References

 
3.1. CPB
Data describing CPB for all patients are as follows: total CPB time was 249±102 min, SCP time was 164±41 min, circulatory arrest time of the lower half body was 88±31 min.

3.2. Hospital mortality
Four patients (3.3%) died within 30 days after operation. Three patients died from low cardiac output syndrome, two of whom had required cardiac massage before operation. The other patient died from mediastinitis 12 days after operation. Another three patients (5.8%) died during hospitalization. The causes were mediastinitis in 1, cerebral bleeding due to uncontrolled anti-coagulation therapy in 1, and multiple organ failure due to liver dysfunction, and sepsis in 1. In univariate analysis risk factors for hospital mortality were prolonged operation time (>600 min) (P=0.029), ruptured aneurysm (P=0.039), and extended repair (P=0.039) (Table 1). In multivariate analysis only ruptured aneurysm was an independent predictor for hospital mortality (Table 2).

	4. Discussion

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A. Conference... References

 
In aortic arch repair, perioperative brain protection is one of the most important subjects. Deep hypothermic circulatory arrest (DHCA) has a disadvantage of a limited safe time, although it has been widely accepted as a good conjunction for brain protection. The incidences of neurological dysfunction and mortality increase with prolonged DHCA [1]. Even adjunctive retrograde cerebral perfusion (RCP) associated with DCHA also has a limited cerebral safe time, although the duration for cerebral safety might be slightly prolonged [2–4]. On the other hand, antegrade SCP is physiological and the time for cerebral safety should be much longer than the others [5]. However, arch-vessel cannulation is required in this maneuver, which is a risk of cerebral embolism. In our institution, both RCP and SCP had been used in aortic arch repair according to surgeons’ preferences. In these circumferences, our previous comparative study [6] demonstrated no difference in the incidence of permanent neurological dysfunction between the two techniques of SCP and RCP. However, it revealed that the incidence of temporary neurological dysfunction was significantly higher in RCP than in SCP. Ergin et al. reported temporary neurological dysfunction was a clinical marker for insidious but significant neurological injury associated with measurable long term deficits in cerebral function [7]. Therefore, since 1998 we have used only SCP in aortic arch repair because of its longer cerebral safety time and low incidence of temporary neurological dysfunction. However, in SCP, atheromatous emboli to the brain, which is considered to be a main cause of permanent neurological dysfunction, remains as a serious major concern. There are lots of embolic sources caused by systemic CPB perfusion via the asc. Ao across the arch aneurysm, or otherwise, retrograde CPB perfusion via the FA, or cannulation to the arch vessels for SCP [8,9].

For the above reasons, we employed AxA perfusion alternatively for both of CPB and SCP. AxA has some advantages for CPB and SCP; it has less atherosclerosis and dissection. It is easy to approach, and to dissect, and cannulate it [10–12]. In addition, antegradely-perfused aortic flow through the AxA conflict with retrogradely perfused FA flow in the descending aorta, which was revealed on transesophageal echocardiography in the operation. By it, cerebral embolism caused by retrograde FA perfusion should be prevented. Instead of FA perfusion, with asc. Ao cannulation for CPB, there is another risk of cerebral emboli. The asc. Ao also has atherosclerotic changes particularly in cases with an atherosclerotic aneurysm. The perfusion jet through the ascending aorta might produce dislodgement of atheroma in the arch to distal arch aneurysms.

In this series, permanent neurological dysfunction was found in 0.8%. This is favorably comparable with that in other studies [5,13–16]. Those reported that 0–3.8% of patients developed permanent neurological dysfunction in total arch replacement using SCP. Among reports with the patients’ number over 100, our series had the lowest incidence of permanent neurological dysfunction.

Between 1993 and 1998, right AxA perfusion was not employed in total arch replacement using SCP for 62 patients because of surgeons’ preferences. CPB was started with FA or asc. Ao cannulation. The brachiocephalic artery as well as the left common carotid arteries was cannulated for SCP. In this series hospital mortality was 12.9%. Permanent neurological dysfunctions developed in 6.5%. A total of 9.7% of the patients suffered from temporary dysfunctions. Obviously, it is difficult to compare the presented series using AxA perfusion with the previous series without AxA perfusion, because the two series did not have randomized control. Patient profile, surgeons, and details of operations were not matched between the two patient groups. However, the incidences of neurological dysfunctions reduced. AxA perfusion might contribute this improvement.

In conclusion, right AxA perfusion in conjunction with SCP for aortic arch surgery is a safe and useful option for brain protection.

	Footnotes

 
Presented at the 16th Annual Meeting of the European Association for Cardio-thoracic Surgery, Monte Carlo, Monaco, September 22–25, 2002.

	Appendix A. Conference discussion

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A. Conference... References

 
Dr A. Moritz (Frankfurt, Germany): First, I have to congratulate you on the very low neurologic complication rate, which is actually lower than those reported for plain coronary artery bypass grafting. So if you achieve this in arch surgery, this is very remarkable.

The second thing is, we could not find exactly your results when we investigated our observations for subclavian artery cannulation. In our comparison we did not see this striking difference you saw.

I have two technical questions for you. One is why do you cannulate the femoral artery in addition, as you could achieve full flow through the subclavian?

And why do you think it's necessary to cannulate selectively the left carotid artery when you can achieve an antegrade flow through the right subclavian and truncus, as it's the very well observation if you do just perfuse antegrade one side you have a serious backflow on the left side. So you have to occlude these vessels during surgery. And why do you think it's necessary to actively antegrade perfuse the left side?

Dr Numata: In terms of the first question about femoral artery cannulation, we used femoral artery perfusion because after the distal anastomosis, we flush out debris and air from the distal part of the aorta by femoral artery perfusion, and we believe it is effective for preventing atheroembolic events of the lower body. So we cannulated the femoral artery as well.

And on the second question regarding the requirement of left common carotid artery cannulation, as you mentioned, we found some backflow from the left common carotid artery before left common carotid artery cannulation. But we did not perfuse the left subclavian artery. We do not think whole brain perfusion is sufficient with only right axillary artery perfusion. So left-side brain perfusion was added. And selective cerebral perfusion was established at the flow rate of 500 ml/min, using a single roller pump, apart from the systemic circulation pump. And the pressure of the both side temporary arteries was monitored, which was controlled between 30 and 50 mmHg by regulating selective cerebral perfusion flow. With this technique, the incidence of temporary neurological dysfunction was only 5.8%, and that of permanent neurological dysfunction was 0.8%, which were favorable results for brain protection, I think.

Dr Moritz: You don't trust on the collateral flow? Or is there any evidence that you need the left antegrade perfusion or you just do it because it has proven to be good?

Dr Numata: Yes, we also trust on it. But, we do not think it is complete.

Dr J. Bachet (Paris, France): I might say, in agreement with Dr Numata, that 15% of the human beings have no functional circle of Willis. So I think it's very dangerous to estimate that cannulating and perfusing only the right side may be safe. If you do that, you're going to get into big trouble. Furthermore, putting a cannula into the left carotid artery takes about 30 s, and it's very safe.

Dr T. Wahlers (Vienna, Austria): When have your patients been extubated? And how do you define delay of awakeness? Because we have seen this phenomenon very often, and I would be interested how you define that. We have observed that problem lasting for about 2–3 days without any neurological deficit, just getting the impression that they had too much anaesthetic narcotics.

Dr Numata: In this study, we defined no full-awakening 1 week after the operation as ‘delay of awakeness’. Our patients are usually extubated on postoperative 1 or 2 day.

Dr C. Yankah (Berlin, Germany): My first question relates to the preoperative assessment of your carotid arteries. Do you check preoperatively whether the carotid artery is clean before attempting this maneuver, in order to avoid embolization?

My second question entails a comment as well. It addresses our experience in evaluating the neurological status of these patients. We reduce the sedation and let the patients become awake during the first 6 h and test for their response to sound and command to open their eyes and move their extremities. I think these are simple clinical findings and very helpful parameters to assess effective cerebral circulation during axillary artery perfusion.

Dr Numata: On the first question about carotid artery, we evaluated preoperatively the both side carotid arteries by Doppler echo. And if over 50% stenosis was found, the patients were referred to neurologist for further assessment or treatment. And if any other treatments were not required, we did the operation with our standard technique.

And I'm sorry, what is the second question?

Dr Yankah: The second question was the evaluation of consciousness of the patient after surgery, to assess effective cerebral circulation. We usually evaluate the awakeness of the patient in the first 6 h by temporarily terminating the sedation. The patient is responsive to sound and calls and can move the extremities if there is no major neurological defect. This is a simple clinical test and an important parameter for evaluating effective cerebral perfusion.

Dr Numata: Comparing with our retrograde cerebral perfusion series, awakeness of selective perfusion series was early and smooth in our experience. And the incidence of temporary neurological dysfunction was lower than that of retrograde series. So we think brain protection using antegrade perfusion is more adequate. We did not do the trial on assessment of the patient's awakeness, which you mentioned. I agree with you. I would do it.

	References

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A. Conference... References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Hitoshi Ogino Motomi Ando Soichiro Kitamura Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Numata, S. Articles by Kitamura, S. Search for Related Content PubMed PubMed Citation Articles by Numata, S. Articles by Kitamura, S. Related Collections Great vessels