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Letters to the Editor |
Division of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
Received 9 March 2009; accepted 6 April 2009.
* Corresponding author. Tel.: +49 511 532 6581; fax: +49 511 532 5404. (Email: Khaladj.Nawid{at}mh-hannover.de).
Key Words: Hypothermic circulatory arrest • Cerebral perfusion • Brain protection • Lower body protection
We read with great interest the article by Miyamoto and colleagues, presented at the 22nd annual meeting of the EACTS 2008 [1]. They raised the interesting topic of different techniques (two- or three-vessel perfusion) for selective antegrade cerebral perfusion (SACP) during thoracic aortic surgery. In this context, they focussed on the impact of lower body perfusion during SACP. They speculate that additional perfusion of the left subclavian artery causes a significant amount of collateral blood flow into the lower body.
In the introduction section of the article, the authors try to convince the reader about the necessity of a three-vessel perfusion in cases of an incomplete circle of Willis. The insufficient circle of Willis is especially a problem in the context of a unilateral cerebral perfusion through the right axillary/subclavian artery, as it is often applied during thoracic aortic surgery [2]. The major concern of bilateral SACP is the steal phenomenon, which can be easily resolved by inserting a Fogarty catheter into the left subclavian artery [3]. The papers cited in the context of the article by Miyamoto and colleagues have focussed on descending thoracic stent grafting and carotid endarterectomy [1].
Unfortunately, the authors failed to provide data on the potential differences of the blood flow to the brain with two- or three-vessel SACP (e.g., near-infrared spectroscopy values). The idea of combining SACP with hypothermic circulatory arrest (HCA) was to allow moderate temperatures for the body and profound temperatures for the brain [4], not increasing the risk of visceral organ damage up to 60 min of HCA [5]. The idea of lower body perfusion techniques are appealing since this technique may allow even mild temperatures by continuously providing blood through the descending aorta or femoral artery; if this is necessary at a core temperature of 20 °C is questionable [1].
In their article, the authors raise the question about the real impact of collateral blood flow on end-organ perfusion. Since only 6.5% of the total SACP reaches the lower body, the effect seems to be negligible, especially compared to 5.3% in the two-vessel perfusion group. The method of blood flow measurement with blood collection via a suction tube is unreliable.
The tissue blood flow of the liver of only 50% of the study patients (22/43) is plotted and seems to increase during additional perfusion of the left subclavian artery, without giving information related to possible correlations of collateral and tissue blood flow. The authors could have easily answered this question by comparing their data with the blood flow of patients during the 2 l min–1 lower body perfusion with prolonged HCA.
Despite a number of flaws in the current study, the authors raised an interesting topic focussing on a whole body perfusion concept during extensive aortic arch surgery. Their article will initiate further studies to try different selective perfusion regimes.
References
This article has been cited by other articles:
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  Y. Miyamoto, S. Fukui, T. Kajiyama, and M. Mituno Reply to Khaladj et al. Eur. J. Cardiothorac. Surg., August 1, 2009; 36(2): 426 - 426. [Full Text] [PDF]
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