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Hisatomi K, Miura T, Obase K, Matsumaru I, Nakaji S, Tanigawa A, Taguchi S, Takura M, Nakao Y, Eishi K. Minimally Invasive Valvular Surgery in the Elderly - Safety, Early Recovery, and Long-Term Outcomes. Circ J 2022; 86:1725-1732. [PMID: 36198575 DOI: 10.1253/circj.cj-22-0338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND For elderly people, the benefit of minimally invasive cardiac surgery (MICS) is unclear, so we evaluated the safety, recovery, and long-term survival in elderly MICS patients.Methods and Results: 63 propensity score-matched pairs of 213 consecutive patients (≥70 years old) who underwent mitral and/or tricuspid valve surgery between 2010 and 2020 (121 right mini-thoracotomies vs. 92 full sternotomies) were compared. The primary outcome was safety (composite endpoint of in-hospital death or major complication). Secondary outcomes were early ambulation and discharge to home. There were no differences between the groups for in-hospital death (3.2% vs. 0.0%, P=0.157) and primary outcome (14.3% vs. 17.5%, P=0.617). The rate of early ambulation (73.0% vs. 55.6%, P=0.048) and discharge to home (66.7% vs. 49.2%, P=0.034) were significantly higher in the mini-thoracotomy group. Major complication was an independent negative predictor of early ambulation for mini-thoracotomy but not for a conservative approach. Survival was 87.8±4.4% vs. 86.8±4.7% at 5 years, which was not significantly different. CONCLUSIONS Similar safety but better recovery were observed for mini-thoracotomy, and long-term survival was comparable between groups. Major complication was a negative predictor of early ambulation after mini-thoracotomy. Careful preoperative risk stratification would enhance the benefits of MICS in elderly patients.
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Affiliation(s)
- Kazuki Hisatomi
- Department of Cardiovascular Surgery, Nagasaki University Hospital
| | - Takashi Miura
- Department of Cardiovascular Surgery, Nagasaki University Hospital
| | - Kikuko Obase
- Department of Cardiovascular Surgery, Nagasaki University Hospital
| | - Ichiro Matsumaru
- Department of Cardiovascular Surgery, Nagasaki University Hospital
| | - Shun Nakaji
- Department of Cardiovascular Surgery, Nagasaki University Hospital
| | - Akihiko Tanigawa
- Department of Cardiovascular Surgery, Nagasaki University Hospital
| | - Shunsuke Taguchi
- Department of Cardiovascular Surgery, Nagasaki University Hospital
| | - Masayuki Takura
- Department of Cardiovascular Surgery, Nagasaki University Hospital
| | - Yuko Nakao
- Department of Cardiovascular Surgery, Nagasaki University Hospital
| | - Kiyoyuki Eishi
- Department of Cardiovascular Surgery, Nagasaki University Hospital
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Tan SZ, Singh S, Austin NJ, Alfonso Palanca J, Jubouri M, Girardi LN, Chen EP, Bashir M. Duration of deep hypothermic circulatory arrest for aortic arch surgery: is it a myth, fiction, or scientific leap? THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:243-253. [PMID: 35238523 DOI: 10.23736/s0021-9509.22.12275-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION The use of deep hypothermic circulatory arrest (DHCA) to provide aortic surgeons with a bloodless operative field while simultaneously protecting the brain and peripheries from ischemic damage revolutionized cardiac and aortic surgery, and is currently used in specialist centers across the globe. However, it is associated with manifold adverse outcomes, including neurocognitive dysfunction and mortality. This review seeks to analyze the relationship between DHCA duration and clinical outcome, and evaluate the controversies and limitations surrounding its use. EVIDENCE ACQUISITION We performed a review of available literature with statistical analysis to evaluate the relationship between DHCA duration (<40 min and >40 min) and key clinical outcomes, including mortality, permanent and temporary neurological deficit, renal damage, admission length, and reintervention rate. The controversies surrounding DHCA use and future directions for care are also explored. EVIDENCE SYNTHESIS Statistical analysis revealed no significant association (P>0.05) between DHCA duration and clinical outcomes (early and late mortality rates, neurological deficit, admission length, and reintervention rate), both with and without adjunctive perfusion techniques. CONCLUSIONS Available literature suggests that the relationships between DHCA duration (with and without adjunctive perfusion) and clinical outcomes are unclear, and at present not statistically significant. Alternative surgical and endovascular techniques have been identified as promising novel approaches not requiring DHCA, as have the use of biomarkers to enable early diagnosis and intervention for aortic pathologies.
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Affiliation(s)
- Sven Z Tan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Sidhant Singh
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Natasha J Austin
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Joaquin Alfonso Palanca
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Matti Jubouri
- Hull York Medical School, University of York, York, UK
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Mohamad Bashir
- Vascular and Endovascular Surgery, Health and Education Improvement Wales, Nantgarw, UK -
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Ohno N, Minatoya K. sArterial cannulation to establish cardiopulmonary bypass during surgery for acute aortic dissection. Surg Today 2019; 50:1353-1359. [PMID: 31773278 DOI: 10.1007/s00595-019-01921-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 10/16/2019] [Indexed: 12/19/2022]
Abstract
A cannulation strategy in surgery for Stanford type A acute aortic dissection (AAAD) is integral for patient survival. Femoral cannulation has been the standard option for cannulation; however, there is increasing evidence that retrograde perfusion with femoral cannulation is associated with worse clinical outcomes, and new cannulation sites have been introduced in surgery for AAAD. Although axillary artery cannulation and central cannulation via the ascending aorta have become more popular than femoral access in recent years, adverse events have been reported and shifting cannulation sites during surgery are recommended by some surgeons. Therefore, it is beneficial for surgeons to broaden their knowledge about cannulation technology for AAAD. In this review, we discuss the various methods of cannulation for AAAD.
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Affiliation(s)
- Nobuhisa Ohno
- Department of Cardiovascular Surgery, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Hyogo, Japan
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University, 54 Kawaharacho, Shogoin, Sakyo-ku, Kyoto, 6068507, Japan.
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Reply: Alternative arterial cannulation in aortic arch surgery. J Thorac Cardiovasc Surg 2019; 158:e167-e168. [PMID: 31351777 DOI: 10.1016/j.jtcvs.2019.06.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 06/13/2019] [Indexed: 11/21/2022]
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Uchino G, Yunoki K, Sakoda N, Saiki M, Hisamochi K, Yoshida H. Innominate artery cannulation for arterial perfusion during aortic arch surgery. J Card Surg 2017; 32:110-113. [DOI: 10.1111/jocs.13091] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Gaku Uchino
- Department of Cardiovascular Surgery, Hiroshima Shimin Hospital; Nakaku, Hiroshimashi; Hiroshima Prefecture Japan
| | - Keiji Yunoki
- Department of Cardiovascular Surgery, Hiroshima Shimin Hospital; Nakaku, Hiroshimashi; Hiroshima Prefecture Japan
- Department of Endovascular Treatment for Structural Heart and Aortic Disease; Hiroshima Shimin Hospital; Hiroshima Prefecture Japan
| | - Naoya Sakoda
- Department of Cardiovascular Surgery, Hiroshima Shimin Hospital; Nakaku, Hiroshimashi; Hiroshima Prefecture Japan
| | - Munehiro Saiki
- Department of Cardiovascular Surgery, Hiroshima Shimin Hospital; Nakaku, Hiroshimashi; Hiroshima Prefecture Japan
- Department of Endovascular Treatment for Structural Heart and Aortic Disease; Hiroshima Shimin Hospital; Hiroshima Prefecture Japan
| | - Kunikazu Hisamochi
- Department of Cardiovascular Surgery, Hiroshima Shimin Hospital; Nakaku, Hiroshimashi; Hiroshima Prefecture Japan
| | - Hideo Yoshida
- Department of Cardiovascular Surgery, Hiroshima Shimin Hospital; Nakaku, Hiroshimashi; Hiroshima Prefecture Japan
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Zierer A, Risteski P, El-Sayed Ahmad A, Moritz A, Diegeler A, Urbanski PP. The impact of unilateral versus bilateral antegrade cerebral perfusion on surgical outcomes after aortic arch replacement: A propensity-matched analysis. J Thorac Cardiovasc Surg 2014; 147:1212-7; discussion 1217-8. [DOI: 10.1016/j.jtcvs.2013.12.022] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Revised: 10/04/2013] [Accepted: 12/04/2013] [Indexed: 11/28/2022]
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Angeloni E, Benedetto U, Takkenberg JJ, Stigliano I, Roscitano A, Melina G, Sinatra R. Unilateral versus bilateral antegrade cerebral protection during circulatory arrest in aortic surgery: A meta-analysis of 5100 patients. J Thorac Cardiovasc Surg 2014; 147:60-7. [DOI: 10.1016/j.jtcvs.2012.10.029] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Revised: 09/15/2012] [Accepted: 10/16/2012] [Indexed: 11/25/2022]
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Yilmazkaya B, Gurkahraman S, Yondem OZ, Hijazi A, Algin IH, Yesilay A. Advantages of upper brachial artery cannulation in aortic surgery. Asian Cardiovasc Thorac Ann 2013; 22:18-24. [PMID: 24585638 DOI: 10.1177/0218492312467540] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND The best method of cerebral protection during aortic arch surgery remains controversial. However, antegrade cerebral perfusion seems to be the most favorable because of better neurological outcomes. Although there have been many studies on antegrade cerebral perfusion via upper brachial cannulation, there is a lack of studies focusing particularly on local complications, with objective findings. The aim of this study was to investigate the local neurological and vascular complications following upper brachial cannulation. METHODS AND RESULTS This study included 44 patients who underwent procedures on the ascending aorta, aortic arch, or descending aorta with upper brachial artery cannulation for cardiopulmonary bypass at OSM Ortadogu Hospital and Cankaya Hospital between January 2009 and April 2012. The mean age of the 32 (72.7%) men and 12 (27.3%) women was 55.2 ± 12.3 years. Doppler analysis of the upper brachial artery was performed in 26 (59%) patients. Mean follow-up time for Doppler analysis was 5.7 ± 2 months. The mean antegrade cerebral perfusion time was 35 ± 16.1 min. The mean degree of hypothermia was 25.1 ± 2.0 . Hospital death occurred in 4 (9.1%) patients, and 2 (4.5%) suffered local neurologic complications. Electromyelography analysis was carried out in the 2 patients who suffered local neurologic symptoms. CONCLUSIONS Brachial artery cannulation is technically simple and less time consuming, thus suitable even for emergency cases. With an acceptable risk of local complications, we recommend routine use of upper brachial cannulation for antegrade cerebral perfusion.
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Affiliation(s)
- Bayram Yilmazkaya
- Department of Cardiovascular Surgery, OSM Ortadogu Hospital, Sanliurfa, Turkey
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9
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Hyperoxia Management During Deep Hypothermia for Cerebral Protection in Circulatory Arrest Rabbit Model. ASAIO J 2012; 58:330-6. [DOI: 10.1097/mat.0b013e318251dfab] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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10
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Kim JW, Choi JY, Rhie S, Lee CE, Sim HJ, Park HO. Clinical Results of Ascending Aorta and Aortic Arch Replacement under Moderate Hypothermia with Right Brachial and Femoral Artery Perfusion. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2011; 44:215-9. [PMID: 22263154 PMCID: PMC3249305 DOI: 10.5090/kjtcs.2011.44.3.215] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2010] [Revised: 03/18/2011] [Accepted: 05/11/2011] [Indexed: 11/16/2022]
Abstract
Background Selective antegrade perfusion via axillary artery cannulation along with circulatory arrest under deep hypothermia has became a recent trend for performing surgery on the ascending aorta and aortic arch and when direct aortic cannulation is not feasible. The authors of this study tried using moderate hypothermia with right brachial and femoral artery perfusion to complement the pitfalls of single axillary artery cannulation and deep hypothermia. Materials and Methods A retrospective analysis was performed on 36 patients who received ascending aorta or aortic arch replacement between July 2005 and May 2010. The adverse outcomes included operative mortality, permanent neurologic dysfunction and temporary neurologic dysfunction. Results Of these 36 patients, 32 (88%) were treated as emergencies. The mean age of the patients was 61.9 years (ranging from 29 to 79 years) and there were 19 males and 17 females. The principal diagnoses for the operation were acute type A aortic dissection (31, 86%) and aneurysmal disease without aortic dissection (5, 14%). The performed operations were ascending aorta replacement (9, 25%), ascending aorta and hemiarch replacement (13, 36%), ascending aorta and total arch replacement (13, 36%) and total arch replacement only (1, 3%). The mean cardiopulmonary bypass time was 209.4±85.1 minutes, and the circulatory arrest with selective antegrade perfusion time was 36.1±24.2 minutes. The lowest core temperature was 24±2.1℃. There were five deaths within 30 post-op days (mortality: 13.8%). Two patients (5.5%) had minor neurologic dysfunction and six patients, including three patients who had preoperative cerebral infarction or unconsciousness, had major neurologic dysfunction (16.6%). Conclusion When direct aortic cannulation is not feasible for ascending aorta and aortic arch replacement, the right brachial and femoral artery can be used as arterial perfusion routes with the patient under moderate hypothermia. This technique resulted in acceptable outcomes.
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Affiliation(s)
- Jong Woo Kim
- Department of Thoracic and Cardiovascular Surgery, College of Medicine and Institute of Health Sciences, Gyeongsang National University, Korea
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11
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Unilateral cerebral perfusion: right versus left. Eur J Cardiothorac Surg 2010; 37:1332-6. [DOI: 10.1016/j.ejcts.2010.01.006] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2009] [Revised: 12/21/2009] [Accepted: 01/05/2010] [Indexed: 11/24/2022] Open
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12
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Ozatik MA, Kocabeyoglu S, Küçüker SA, Saritas A, Altintas G, Kervan U, Yavas S, Paç M. Neurochemical markers during selective cerebral perfusion via the right brachial artery. Interact Cardiovasc Thorac Surg 2010; 10:948-52. [PMID: 20233805 DOI: 10.1510/icvts.2009.228858] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Unilateral selective cerebral perfusion through right brachial artery is one of the cerebral protection methods for aortic arch repair. The purpose of this study is to determine whether cerebral perfusion through contra-lateral hemisphere is adequate or not. Seventeen consecutive patients underwent aortic arch repair using low flow antegrade selective cerebral perfusion (ASCP) through right brachial artery under moderate hypothermia. We measured S100beta and neuron-specific enolase (NSE) levels, venous O(2) saturation, lactate, and glucose from both left and right jugular vein blood samples before, during and following ASCP and cardiopulmonary bypass. There was no operative mortality or neurological complication in these patients. No significant differences were observed in S100beta and NSE levels, venous saturation, glucose and lactate between the blood samples which were gathered from both jugular veins, statistically. This technique, as far as biochemical markers are concerned, seems to provide adequate perfusion for both right and left cerebral hemispheres.
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Affiliation(s)
- Mehmet Ali Ozatik
- Cardiovascular Surgery Clinic, Türkiye Yüksek Ihtisas Education and Research Hospital, 06100 Sihhiye, Ankara, Turkey.
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13
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Reply to the Editor. J Thorac Cardiovasc Surg 2010. [DOI: 10.1016/j.jtcvs.2009.10.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Kucuker A, Sener E. Safety of axillary artery cannulation. J Thorac Cardiovasc Surg 2010; 139:797; author reply 797-8. [PMID: 20176225 DOI: 10.1016/j.jtcvs.2009.10.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2009] [Accepted: 10/03/2009] [Indexed: 11/25/2022]
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Kaul P, Javangula K, Ganti S, Balaji S, Sivananthan M, Gough M, Lindsay S. Continuous selective bilateral antegrade cerebral perfusion through anomalous innominate artery for repair of root, ascending aortic and arch aneurysm – challenges, vagaries and opportunities of bovine arch variant anatomy and review of literature. Perfusion 2009; 24:121-33. [DOI: 10.1177/0267659109106774] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We describe the repair of a root, ascending aortic and arch aneurysm in a 69-year-old man with a bioprosthetic Shelhigh conduit and cylinder, employing continuous bilateral antegrade cerebral perfusion through an anomalous innominate artery with a bovine arch variant anatomy. The origin of both the innominate artery and the left common carotid artery from a common stem from the arch in this bovine arch variant puts the whole cerebral circulation at risk, on one hand, yet provides an opportunity of continuous bilateral antegrade cerebral perfusion through the right brachial, right axillary, right subclavian or innominate artery, during arch reconstruction under lower body, deep hypothermic circulatory arrest. Safety and adequacy of selective cerebral perfusion through the right axillary artery in patients with normal arch vessel origin depends on an intact circle of Willis. In this bovine arch variant, both cerebral hemispheres can be perfused through the right brachial, right axillary, right subclavian or the innominate artery, independent of the integrity of the circle of Willis, because of the origin of the left common carotid artery from the innominate artery, except for the area supplied by the left vertebral artery. Although this is the first report of innominate artery perfusion for arch reconstruction for aneurysm in a bovine arch variant, we believe the method described has important implications for cerebral protection in light of the generally reported incidence of bovine arch from 13 to 35 percent.
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Affiliation(s)
- P Kaul
- Department of Cardiothoracic Surgery, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK
| | - K Javangula
- Department of Cardiothoracic Surgery, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK
| | - S Ganti
- Department of Cardiothoracic Surgery, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK
| | - S Balaji
- Department of Cardiothoracic Surgery, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK
| | - M Sivananthan
- Department of Cardiac Radiology, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK
| | - M Gough
- Department of Vascular Surgery, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK
| | - S Lindsay
- Department of Cardiology, Bradford Royal Infirmary, Duckworth Lane, Bradford BD9 6RJ, UK
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Advantages of right axillary artery cannulation in surgical management of thoracic aorta dissection involving the aortic arch. COR ET VASA 2009. [DOI: 10.33678/cor.2009.124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Emrecan B, Tulukoğlu E. A Current View of Cerebral Protection in Aortic Arch Repair. J Cardiothorac Vasc Anesth 2009; 23:417-20. [DOI: 10.1053/j.jvca.2009.01.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2006] [Indexed: 11/11/2022]
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Akgul A. Behçet's inflammatory vessels for cannulation in inflammatory aortic repair. Ann Thorac Surg 2009; 87:1649; author reply 1649-50. [PMID: 19379940 DOI: 10.1016/j.athoracsur.2008.12.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2008] [Revised: 10/26/2008] [Accepted: 12/02/2008] [Indexed: 11/24/2022]
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Battaloglu B, Erdil N, Nisanoglu V. Axillary Artery Perfusion in Acute Type A Aortic Dissection Repair. J Card Surg 2008; 23:693-6. [DOI: 10.1111/j.1540-8191.2008.00754.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Bektas Battaloglu
- Department of Cardiovascular Surgery, Inonu University, Turgut Ozal Medical Center, Malatya, Turkey
| | - Nevzat Erdil
- Department of Cardiovascular Surgery, Inonu University, Turgut Ozal Medical Center, Malatya, Turkey
| | - Vedat Nisanoglu
- Department of Cardiovascular Surgery, Inonu University, Turgut Ozal Medical Center, Malatya, Turkey
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Malvindi PG, Scrascia G, Vitale N. Is unilateral antegrade cerebral perfusion equivalent to bilateral cerebral perfusion for patients undergoing aortic arch surgery? Interact Cardiovasc Thorac Surg 2008; 7:891-7. [DOI: 10.1510/icvts.2008.184184] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Saritas A, Yavas S, Kervan U, Demirtas E, Ulus AT. Unilateral brachial artery antegrade selective cerebral perfusion following carotid endarterectomy for carotid, coronary, and aortic aneurysmal surgery. J Card Surg 2008; 24:178-80. [PMID: 18793231 DOI: 10.1111/j.1540-8191.2008.00726.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
In the presence of multiple concomitant occlusive and aneurysmal diseases, selection of the brain protection method is a primary concern. A case with a disease triad of stenotic lesions in internal carotid arteries, coronary artery atherosclerosis, and an ascending-arcus aorta aneurysm is presented. We simultaneously performed right carotid endarterectomy, coronary artery bypass grafting, and graft replacement of the ascending-arcus aorta. Brain protection was achieved with continuous right brachial artery antegrade selective cerebral perfusion under moderate hypothermia, following carotid endarterectomy. The operative technique is detailed and antegrade selective cerebral perfusion following the carotid endarterectomy for aneurysmal surgery is discussed.
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Affiliation(s)
- Ahmet Saritas
- Turkiye Yuksek Ihtisas Hospital, Cardiovascular Surgery Clinic, Ankara, Turkey
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Gulbins H. Reply. Ann Thorac Surg 2008. [DOI: 10.1016/j.athoracsur.2008.04.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Brachial Cannulation Instead of Axillary and Subclavian Cannulation. Ann Thorac Surg 2008; 86:1057-8; author reply 1058. [DOI: 10.1016/j.athoracsur.2008.03.065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2008] [Revised: 02/20/2008] [Accepted: 03/27/2008] [Indexed: 11/22/2022]
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Merkkola P, Tulla H, Ronkainen A, Soppi V, Oksala A, Koivisto T, Hippeläinen M. Incomplete Circle of Willis and Right Axillary Artery Perfusion. Ann Thorac Surg 2006; 82:74-9. [PMID: 16798193 DOI: 10.1016/j.athoracsur.2006.02.034] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2005] [Revised: 02/09/2006] [Accepted: 02/09/2006] [Indexed: 11/22/2022]
Abstract
BACKGROUND The aim of our anatomic study was to assess whether the commonly used method of perfusion through the right axillary artery is sufficient in providing uniform distribution of blood to both hemispheres of the brain in patients undergoing surgery of the aortic arch. We considered that critical arteries to examine are anterior and left posterior communicating arteries of the circle of Willis because the absence or insufficiency of either one would drastically endanger perfusion to the left hemisphere of the brain. The existence and the diameters of these arteries were studied. METHODS The material was collected as a part of normal forensic medicine autopsies. The anatomy of the cerebral arteries of 87 deceased individuals was assessed by angiography and permanent silicone casts. A new classification was created for this study. According to a recent observation in the literature we defined the minimum threshold of arterial diameter that allows cross flow to be 0.5 mm. We also repeated analyses using 1 mm as a threshold, which has also been recommended. RESULTS In our material 22% of the anterior communicating arteries and 46% of the left posterior communicating arteries were missing. In this anatomic population the perfusion to the left hemisphere might have been insufficient in 14% of the patients at a threshold of 0.5 mm and in 17% at a threshold of 1 mm. CONCLUSIONS When the right axillary artery is used for perfusion, the circulation to the contralateral hemisphere seems to be good for most patients undergoing operations of the aortic arch, but additional means of brain protection are still needed.
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Affiliation(s)
- Päivi Merkkola
- Department of Thoracic and Cardiovascular Surgery, Kuopio University Hospital, Kuopio, Finland
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Field ML, Al-Alao B, Mediratta N, Sosnowski A. Open and closed chest extrathoracic cannulation for cardiopulmonary bypass and extracorporeal life support: methods, indications, and outcomes. Postgrad Med J 2006; 82:323-31. [PMID: 16679471 PMCID: PMC2563780 DOI: 10.1136/pgmj.2005.037929] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2005] [Accepted: 09/19/2005] [Indexed: 11/04/2022]
Abstract
Extrathoracic cannulation to establish cardiopulmonary bypass has been widely applied in recent years and includes: (a) repeat surgery, (b) minimally invasive surgery, and (c) cases with diseased vessels such as porcelain, aneurysmal, and dissecting aorta. In addition, the success and relative ease of peripheral cannulation, among other technological advances, has permitted the development of closed chest extracorporeal life support, in the form of cardiopulmonary support and extracorporeal membrane oxygenation. With this development have come applications for cardiopulmonary bypass based support outside the traditional cardiac theatre setting, including emergency circulatory support for patients in cardiogenic shock and respiratory support for patients with severely impaired gas exchange. This review summarises the approach to extrathoracic cannulation for the generalist.
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Affiliation(s)
- M L Field
- Cardiothoracic Centre, Liverpool L14 3PE, UK.
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Olsson C, Thelin S. Antegrade Cerebral Perfusion With a Simplified Technique: Unilateral Versus Bilateral Perfusion. Ann Thorac Surg 2006; 81:868-74. [PMID: 16488686 DOI: 10.1016/j.athoracsur.2005.08.079] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2005] [Revised: 07/29/2005] [Accepted: 08/15/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Selective antegrade cerebral perfusion has been introduced as a strategy of cerebral protection in operations on the aortic arch with hypothermic circulatory arrest. Several techniques of unilateral and bilateral cerebral perfusion have been described with varying results. METHODS Patients underwent either unilateral cerebral perfusion with a cannula in the right subclavian artery or bilateral cerebral perfusion, with an additional cannula in the left carotid artery. A simplified Seldinger-type technique for subclavian artery cannulation was employed. Results were analyzed with multivariable logistic regression analysis and propensity score analysis to adjust for nonrandomized treatment assignment. RESULTS Of 65 patients, 17 (26%) had unilateral cerebral perfusion. Mortality was 11% (n = 7); 14% (n = 9) had a stroke. In multivariable analysis, unilateral cerebral perfusion was significantly associated with stroke (odds ratio 6.6 [1.2 to 36]). Age more than 70 years was associated with in-hospital death (odds ratio 12 [1.3 to 113]), and concomitant coronary artery bypass graft surgery was associated with adverse outcome (odds ratio 23 [1.8 to 299]). Balancing variables in a propensity score analysis, stroke remained significantly more common with unilateral brain perfusion (29% versus 0%, p = 0.045). Complications associated with subclavian artery cannulation were encountered in 1 patient (1.5%). CONCLUSIONS The described cannulation technique is safe and effective. Bilateral cerebral perfusion is easily achieved and is associated with decreased stroke risk, and should be the preferred brain protection strategy.
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Affiliation(s)
- Christian Olsson
- Division of Cardiothoracic Surgery, Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden.
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Karadeniz U, Erdemli O, Ozatik MA, Yamak B, Demirci A, Küçüker SA, Saritaş A, Taşdemir O. Assessment of Cerebral Blood Flow With Transcranial Doppler in Right Brachial Artery Perfusion Patients. Ann Thorac Surg 2005; 79:139-46; discussion 146. [PMID: 15620931 DOI: 10.1016/j.athoracsur.2004.06.046] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/11/2004] [Indexed: 11/30/2022]
Abstract
BACKGROUND Antegrade selective cerebral perfusion as a method of cerebral protection during the correction of aortic arch aneurysms and dissections is considered as a safe method for cerebral protection. There are still some questions remaining to be answered; such as whether cerebral perfusion through contralateral hemisphere is adequate. METHOD Fifteen consecutive patients (mean age of 53 +/- 3.3 years) underwent surgical reconstruction of aortic arch with antegrade selective cerebral perfusion through the right brachial artery. We monitored maximum, minimum and mean blood flow velocities of bilateral middle cerebral arteries using the transcranial Doppler technique at four different time periods: after induction of anesthesia, during cardiopulmonary bypass, during antegrade selective cerebral perfusion, and after termination of cardiopulmonary bypass. We compared the results of brachial cannulation group with aortic group. RESULTS Following induction, no significant differences were observed in the right and left middle cerebral artery blood flow velocity measurements in and between the groups. During cardiopulmonary bypass, V(max) and V(mean) decreased significantly in both groups. When two groups were compared there was a significant decrease in the left V(max) values of brachial group (p = 0.048). In-group comparisons revealed that V(max) values were lower in left middle cerebral artery than right middle cerebral artery in brachial group (p = 0.002). With the initiation of antegrade selective cerebral perfusion in brachial group, significant decrease occurred in V(max) and V(mean) when compared with cardiopulmonary bypass values. When left and right sides were compared, although V(min) values remained similar, V(max) and V(mean) values decreased significantly in the left side (p = 0.001 and p = 0.003, respectively). After cardiopulmonary bypass, in both groups, all values restored to initial values and indicated no difference between left and right middle cerebral artery in the groups as well as between the groups. No neurologic deficit was observed in any patient postoperatively. CONCLUSIONS Antegrade selective cerebral perfusion through the right brachial artery, as a method of cerebral protection for aortic arch repair, seems to provide adequate perfusion for both right and left cerebral hemispheres.
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Affiliation(s)
- Umit Karadeniz
- Department of Anesthesiology and Reanimation, Turkiye Yuksek Ihtisas Education and Research Hospital, Ankara, Turkey
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Kouchoukos NT, Mauney MC, Masetti P, Castner CF. Single-stage repair of extensive thoracic aortic aneurysms: Experience with the arch-first technique and bilateral anterior thoracotomy. J Thorac Cardiovasc Surg 2004; 128:669-76. [PMID: 15514593 DOI: 10.1016/j.jtcvs.2004.06.037] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Staged procedures for extensive aneurysmal disease of the thoracic aorta are associated with a substantial cumulative mortality (>20%) that includes hospital mortality for the 2 procedures and death (often from aortic rupture) in the interval between the 2 procedures. We have used a single-stage technique for operative repair of most or all of the thoracic aorta. METHODS Forty-six patients with extensive disease of the thoracic aorta were managed with a single-stage procedure by using a bilateral anterior thoracotomy and transverse sternotomy, hypothermic circulatory arrest, and reperfusion of the aortic arch vessels first to minimize brain ischemia. Thirty-one patients with chronic, expanding type A aortic dissections had previous operations for acute type A dissection (n = 22), aortic valve repair or replacement (n = 4), coronary artery bypass grafting (n = 4), or no previous operation (n = 1). The remaining 15 patients had degenerative aneurysms (n = 12) or chronic type B dissections with proximal extension (n = 3). The ascending aorta and aortic arch were replaced in all patients combined with resection of various lengths of descending aorta (proximal one third [n = 19], proximal two thirds to three quarters [n = 22], or all [n = 5]). Coronary artery bypass grafting, valve replacement, or both were performed concomitantly in 19 patients. RESULTS Hospital mortality was 6.5% (3 patients). Morbidity included reoperation for bleeding (17%), mechanical ventilation for more than 72 hours (42%), temporary tracheostomy (13%), and temporary renal dialysis (9%). No patient sustained a stroke. There have been 5 late deaths (3, 18, 34, 51, and 79 months postoperatively) unrelated to the aortic disease. Four patients have undergone successful reoperation on the aorta (false aneurysm [n = 1], endocarditis [n = 1], and progression of disease [n = 2]). Five-year survival was 75%. CONCLUSION The single-stage, arch-first technique is a safe and suitable alternative to the 2-stage procedure for repair of extensive thoracic aortic disease.
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Affiliation(s)
- Nicholas T Kouchoukos
- Division of Cardiovascular and Thoracic Surgery, Missouti Baptist Medical Center, 3009 N. Ballas Road, St. Louis, MO, USA.
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Ozatik MA, Küçüker SA, Tülüce H, Sartiaş A, Sener E, Karakaş S, Taşdemir O. Neurocognitive functions after aortic arch repair with right brachial artery perfusion. Ann Thorac Surg 2004; 78:591-5. [PMID: 15276528 DOI: 10.1016/j.athoracsur.2004.01.052] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/09/2004] [Indexed: 11/18/2022]
Abstract
BACKGROUND Satisfactory neurologic outcome following aortic arch repair through right brachial artery perfusion is well established. However, how neurocognitive functions are affected following selective cerebral perfusion, still needs to be elucidated. METHODS In a period between April 2002 and March 2003, 22 patients (19 male, 3 female, with a mean age of 46.8 +/- 12; range: 26 to 70 years old), underwent aortic arch repair using right brachial artery low flow (8 to 10 mL x kg(-1) x min(-1)) selective antegrade cerebral perfusion under moderate hypothermia (26 degrees C). There were 6 Stanford type-A dissections and 16 ascending aortic aneurysms. All patients were evaluated preoperatively and postoperatively (at seventh day and second month) for neurocognitive functions. RESULTS There was no operative mortality. The average cardiopulmonary bypass time was 115.0 +/- 24.2 minutes and the average antegrade cerebral perfusion time was 29.8 +/- 7.1 minutes (19 to 38 minutes). No major neurologic deficit was observed in the postoperative period. In terms of neurocognitive test results, between the preoperative and postoperative assessments for both hemispheric cognitive functions no deterioration was detected. CONCLUSIONS The low-flow selective antegrade cerebral perfusion technique through the right brachial artery may safely be used for the great majority of patients undergoing aortic arch repair without causing deteriorations in neurocognitive functions.
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Demirkilic U, Kuralay E, Cingoz F, Bingol H, Gunay C, Yildirim V, Kilic S, Tatar H. Brachial Artery Cannulation Facilitates Lower Ministernotomy Cardiac Surgery. J Card Surg 2004; 19:260-3. [PMID: 15151658 DOI: 10.1111/j.0886-0440.2004.04064.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Lower ministernotomy has become a more popular approach for many heart operations. However, cannulation of the ascending aorta may cause serious complications. Femoral and brachial arteries have been used for alternative arterial cannulation sites. MATERIALS AND METHODS The lower ministernotomy approach was used in 65 patients. Ascending aortic cannulation was performed in group 1 (n = 38), femoral cannulation in group 2 (n = 12), and brachial cannulation in group 3 (n = 15) patients. Brachial artery diameter was measured preoperatively by Doppler ultrasound in the preoperative period. RESULTS Average cross-clamp time for femoral and brachial artery cannulated patients was significantly shorter than in patients in group 1 (31 +/- 9 and 35 +/- 6 minutes, respectively) (p = 0.034). Total cardiopulmonary bypass (CPB) time was 56 +/- 11 minutes for group 1, 39 +/- 7 minutes for group 2, and 41 +/- 5.4 minutes for group 3 (p = 0.041). Operation time was 112 +/- 24, 88 +/- 12, and 91 +/- 11 minutes for the groups 1, 2, and 3, respectively. There was also statistically significant difference between group 1 and group 3 comparisons with regard to CPB time (p = 0.041). Difficult exposure from many cannulas impedes access and lengthens the operation in group I. Superficial wound infection developed in seven patients in group 1, one patient in group 2, and one patient in group 3. CONCLUSION Cannulation of the brachial artery is superior to the femoral due to possible infection and lymph leakage with the latter and both are superior to central cannulation when lower ministernotomy is performed. By avoiding the difficulties of central aortic cannula placement the operative time is decreased and possible wound edge is protected as lesser exposure is required.
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Affiliation(s)
- Ufuk Demirkilic
- Department of Cardiovascular Surgery, Gülhane Military Medical Academy, Etlik, Ankara, Turkey.
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Akgul A, Ozatik MA, Kucuker SA, Bahar I, Tasdemir O. Repair of the aortic arch with left unilateral selective cerebral perfusion. Perfusion 2004; 19:77-9. [PMID: 15072260 DOI: 10.1191/0267659104pf706cr] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 67-year-old woman who presented with chest and back pain was diagnosed with an aneurysm of the ascending aorta. Coronary angiography and aortography were performed via the right brachial artery, which was complicated by axillary artery dissection. At surgery, despite our clinical experience of using the right upper brachial artery for arterial cannulation, right femoral artery cannulation was performed to establish cardiopulmonary bypass (CPB) as the dissection was extending to the brachiocephalic artery. The aortic crossclamp was placed on the arch of the aorta just after the origin of the brachiocephalic artery so that cerebral perfusion was performed via the left common carotid and left vertebral and basilar arteries through the left subclavian artery. No neurologic event was observed during the intensive care unit stay and follow-up period. To the best of our knowledge, the literature contains no other report of the use of only the left carotid and subclavian arteries to perfuse cerebral structures during CPB.
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Affiliation(s)
- Ahmet Akgul
- Turkiye Yuksek Ihtisas Hospital, Department of Cardiovascular Surgery, Ankara, Turkey.
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Kuralay E, Bolcal C, Cingoz F, Günay C, Yildirim V, Kilic S, Ozal E, Demirkilic U, Arslan M, Tatar H. Cardiac reoperation by Carpentier bicaval femoral venous cannula: GATA experience. Ann Thorac Surg 2004; 77:977-81; discussion 982. [PMID: 14992910 DOI: 10.1016/j.athoracsur.2003.09.064] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/08/2003] [Indexed: 11/21/2022]
Abstract
BACKGROUND Division of the sternum is primarily a blind procedure in reoperation and carries an increased risk of injury for major cardiac structures in the presence of adhesions between the posterior table and the heart. METHODS Two hundred patients were randomly divided into two groups. Cardiopulmonary bypass was established through the femoral artery and vein in group 1 (n = 100) patients before sternal reentry. Carpentier dual-stage femoral venous return cannula was used in all group 1 patients. Cardiopulmonary bypass was performed after sternal reentry in group 2 (n = 100) patients. RESULTS Six severe cardiac injuries developed in group 2. Cardiopulmonary bypass time was 93 +/- 9 minutes in group 1 and 71 +/- 11 minutes in group 2 (p = 0.011), and the operation time was 155 +/- 23 minutes in group 1 and 185 +/- 32 minutes in group 2 (p = 0.024). Inotropic therapy was required in 52 patients in group 1 and 76 patients in group 2 (p = 0.032). Average chest drainage was 450 +/- 135 mL in group 1 and 850 +/- 250 mL in group 2 (p < 0.001). Average fresh whole blood transfusion was 3.3 +/- 1.2 U in group 1 and 5.8 +/- 0.9 U in group 2 (p = 0.033). Average intensive care unit stay was 2.2 +/- 1.3 days in group 1 and 4.5 +/- 2.3 days in group 2 (p = 0.025). Average hospital stay was 7.3 +/- 2.4 days in group 1 and 9.1 +/- 3.1 days for group 2 (p = 0.011). CONCLUSIONS Cardiopulmonary bypass by bicaval Carpentier femoral venous cannula before resternotomy not only allows adequate cardiopulmonary bypass flow but also significantly reduces the risk of cardiac injury and catastrophic hemorrhage and allows safe reopening. Although this procedure increases cardiopulmonary bypass time, the operation time, bleeding, and blood transfusion requirement are significantly reduced.
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Affiliation(s)
- Erkan Kuralay
- Department of Cardiovascular Surgery, Gülhane Military Medical Academy, Ankara, Turkey.
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Murakami T, Kuinose M, Takagaki M, Inagaki E. Mitral valve replacement through right thoracotomy after previous coronary artery bypass grafting: the usefulness of brachial artery cannulation, perfused ventricular fibrillation with moderate hypothermia, and minimal dissection techniques. ACTA ACUST UNITED AC 2004; 52:26-9. [PMID: 14760988 DOI: 10.1007/s11748-004-0057-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
It has been reported by several authors that a right thoracotomy for mitral valve surgery can be useful after previous coronary aortery bypass grafting (CABG). A 76-year-old man with mitral valve regurgitation after previous CABG underwent mitral valve replacement with some modified techniques. Cardiopulmonary bypass was established with right brachial artery cannulation and right femoral venous cannulation with the aid of vacuum-assisted venous drainage. Ventricular fibrillation (VF) was induced by rapid pacing of the ventricle, and mitral valve replacement was performed under perfused VF with moderate hypothermia. The patient's postoperative course was uneventful. This method appears to be a safe and easy alternative mitral valve surgery for complicated cases of this type.
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Affiliation(s)
- Takashi Murakami
- Department of Cardiovascular Surgery, Iwakuni National Hospital, 2-5-1 Kuroiso-cho, Iwakuni, Yamaguchi 740-8510, Japan
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Kucuker SA, Tasdemir O. Brachial artery cannulation. J Thorac Cardiovasc Surg 2003; 126:2106-7; author reply 2107. [PMID: 14688744 DOI: 10.1016/s0022-5223(03)01047-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Fitzgerald D, Resley J, Speir A, Munoz R, Hill A. Antegrade cerebral perfusion with hypothermic circulatory arrest: a case report. Perfusion 2003; 18:303-6. [PMID: 14604248 DOI: 10.1191/0267659103pf669oa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Techniques for the surgical correction of aortic aneurysms have steadily improved since the first described successful repair in 1955 by DeBakey et al. Despite these improvements, postoperative neurological complications remain a major factor in determining an adverse outcome. By using Deep Hypothermic Circulatory Arrest (DHCA), Retrograde Cerebral Perfusion (RCP) and now Selective Antegrade Cerebral Perfusion (SACP), the surgeon may provide better cerebral protection during extensive arch reconstruction. A 73-year-old female presented with an abnormal chest X-ray. Computerized tomography scan revealed a 4.5 cm mid aortic saccular arch aneurysm. Surgical intervention using cardiopulmonary bypass (CPB) with systemic cooling to 24 degrees C was employed. SACP was administered via cannulation of the innominate artery and the left common carotid artery using pediatric cannulae. Flow rates of 10 mL/kg/min and perfusion pressures of 60-90 mmHg were employed. Transcranial oximetry was used to monitor cerebral oxygen consumption. Circulatory arrest with SACP lasted for 36 min. Total bypass time was 178 min and myocardial ischemic time was 63 min. The patient was discharged on postoperative day five with no evident sequelae. While RCP has many benefits, SACP as used in this procedure may further improve patient outcome.
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Affiliation(s)
- David Fitzgerald
- INOVA Fairfax Hospital, Perfusion Department, Falls Church, Virginia 22046, USA.
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Takahara Y, Mogi K, Sakurai M, Nishida H. Total aortic arch grafting via median sternotomy using integrated antegrade cerebral perfusion. Ann Thorac Surg 2003; 76:1485-9; discussion 1489. [PMID: 14602272 DOI: 10.1016/s0003-4975(03)00720-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND In aortic arch grafting, antegrade cerebral perfusion prolongs the safe time of arch exclusion. However, there are the problems of cerebral embolism and distribution of the cerebral perfusion. We describe and analyze mortality and cerebral complications in patients undergoing total arch grafting using our refined technique. METHODS Between June 1994 and March 2002, 100 consecutive patients underwent total arch grafting through median sternotomy. There were 49 atherosclerotic aneurysms and 51 aortic dissections. Fifty-four patients were operated on an emergency basis because of rupture or acute type A dissection. We conducted total arch grafting using hypothermic antegrade cerebral perfusion from every cervical vessel. Carbon dioxide gas was added to the cerebral perfusion in order to inhibit the increase in the cerebral vascular resistance during hypothermic cerebral perfusion. RESULTS Hospital mortality was 4%. The causes of death were dysarrhythmia (n = 1), mesenteric necrosis (n = 1), and preoperative cardiac arrest (n = 2). On univariate analysis, preoperative shock and concomitant cardiac procedures were risk factors for hospital death. The rate of postoperative neurologic damage was 5%. Two patients suffered from cerebral infarction. Temporary neurologic dysfunction occurred in 3 patients. On univariate analysis, emergency surgery was a risk factor for postoperative neurologic damage. On multivariate analysis, there was no significant independent predictor of hospital mortality and neurologic damage. Actuarial survival at 96 months was 66.4 +/- 9.1%, and freedom from aortic accidents (reoperation, rupture, and cholesterol embolism) was 74.9 +/- 7.9%. CONCLUSIONS The early- and long-term results of total arch grafting using integrated antegrade cerebral perfusion were found to be satisfactory.
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Affiliation(s)
- Yoshiharu Takahara
- Division of Cardiovascular Surgery, Funabashi Municipal Medical Center, Chiba, Japan.
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Bayazit M, Tarcan O, Küçüker S, Süha Küçükaksu D, Taşdemir O. Use of axillary artery to maintain cerebral perfusion in a patient requiring reconstruction of the brachiocephalic trunk and coronary arteries: technical note. J Vasc Surg 2003; 37:1332-3. [PMID: 12764287 DOI: 10.1016/s0741-5214(02)75462-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Our patient had 80% stenosis of the brachiocephalic artery and total occlusion of the left carotid and left subclavian arteries. Ascending aorta to brachiocephalic artery bypass grafting was performed, with a 10 mm Dacron graft. The right axillary artery was cannulated, and during construction of the distal anastomosis cerebral blood flow was from the right axillary artery. We believe this technique may be beneficial in surgery on an artery in which cerebral blood flow depends exclusively.
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Affiliation(s)
- Murat Bayazit
- Türkiye Yüksek Ihtisas Hospital, Cardiovascular Surgery Department, Ankara, Turkey.
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