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Ünal EU, Kubat E, Soran Türkcan B, Kiriş E, Demir A, Aytekin B, Akkaya B, Aksu U, Aksöyek A. Visceral oxidative stress during antegrade cerebral perfusion and lower body circulatory arrest. Acta Chir Belg 2018; 119:217-223. [PMID: 30103668 DOI: 10.1080/00015458.2018.1500798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Background: Antegrade cerebral perfusion (ACP) is the standard neuroprotection method in aortic surgery. Visceral ischemia during this modality brings out some controversies. We aimed to investigate the level of oxidative stress at the lower part of body during ACP. Methods: Thirty consecutive patients underwent elective ascending aorta and hemiarch repair with ACP (without distal perfusion) were enrolled to study. The patients were enrolled into two groups which were based on 50th percentile of ACP duration (15 patients in each group). Blood samples from inferior vena cava at the end of ACP were collected to assess oxidative stress with biochemical parameters such as lactate, advanced oxidative protein products (AOPP) and thiol levels. Clinical follow-up parameters regarding to visceral and spinal cord ischemia were recorded. There were no clinical complications at both groups. Results: Mean ACP duration for the study group was found to be 15 min (10-28 min). Lactate, AOPP, and thiol levels were found to be similar between two groups. Furthermore, correlation analysis revealed only low level of correlation between ACP duration and lactate levels. Renal and liver function tests were found to be similar between groups. Conclusions: Immediate parameters (such as lactate, AOPP, and thiol) that show alterations in response to oxidative stress were not affected by the duration of ACP. Therefore, ACP without distal perfusion may not be harmful when conducted for short duration.
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Affiliation(s)
- Ertekin Utku Ünal
- Department of Cardiovascular Surgery, Turkey Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Emre Kubat
- Department of Cardiovascular Surgery, Karabük Devlet Hastanesi, Karabük, Turkey
| | - Başak Soran Türkcan
- Department of Cardiovascular Surgery, Turkey Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Erman Kiriş
- Department of Cardiovascular Surgery, Turkey Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Aslı Demir
- Department of Anesthesiology and Reanimation, Turkey Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Bahadır Aytekin
- Department of Cardiovascular Surgery, Turkey Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Boğaçhan Akkaya
- Department of Cardiovascular Surgery, Turkey Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Uğur Aksu
- Department of Biology, Faculty of Science, Istanbul University, Istanbul, Turkey
| | - Ayşen Aksöyek
- Department of Cardiovascular Surgery, Turkey Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
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Manetta F, Mullan CW, Catalano MA. Neuroprotective Strategies in Repair and Replacement of the Aortic Arch. Int J Angiol 2018; 27:98-109. [PMID: 29896042 PMCID: PMC5995688 DOI: 10.1055/s-0038-1649512] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Aortic arch surgery is a technical challenge, and cerebral protection during distal anastomosis is a continued topic of controversy and discussion. The physiologic effects of hypothermic arrest and adjunctive cerebral perfusion have yet to be fully defined, and the optimal strategies are still undetermined. This review highlights the historical context, physiological rationale, and clinical efficacy of various neuroprotective strategies during arch operations.
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Affiliation(s)
- Frank Manetta
- Department of Cardiovascular and Thoracic Surgery, Barbara and Donald Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Clancy W. Mullan
- Department of Cardiovascular and Thoracic Surgery, Barbara and Donald Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Michael A. Catalano
- Department of Cardiovascular and Thoracic Surgery, Barbara and Donald Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
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Miyamoto S, Takahashi S, Okahara S, Takahashi H, Katayama K, Watanabe M, Maeda K, Go S, Morita S, Kurosaki T, Herlambang B, Sueda T. Abdominal organ protection strategy for aortic arch aneurysm surgery. Perfusion 2018; 33:512-519. [PMID: 29635960 DOI: 10.1177/0267659118768149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Body temperature maintained during open distal anastomosis in patients who undergo aortic surgery has been showing an upward trend; however, a higher temperature may increase visceral organ and spinal cord injury. Distal perfusion may reduce abdominal organ injury, especially acute kidney injury (AKI). METHODS From 2009 to 2016, 56 patients who underwent ascending aortic and/or aortic arch surgery were enrolled. Open distal anastomosis was performed using one of three protection strategies: 1) systemic temperature of 25°C followed by selective cerebral perfusion (SCP) with lower body circulatory arrest (Group CA25, n=27); 2) systemic temperature of 28°C followed by SCP with lower body circulatory arrest (Group CA28, n=4); and 3) systemic temperature of 28°C followed by SCP with distal aortic perfusion (Group DP, n=25). RESULTS During the postoperative course, levels of blood urea nitrogen, creatinine, liver enzymes, lactate dehydrogenase and lactate in Groups CA28 and CA25 were significantly higher than those in Group DP. AKI defined by the AKI Network occurred in 28 cases (50%) and 3 cases required permanent hemodialysis. AKI was significantly higher in Groups CA25 and CA28 than in Group DP (p=0.026). Mid-term follow-up showed that patients who developed postoperative AKI were more likely to suffer from cardiovascular events. CONCLUSIONS Distal perfusion during open distal anastomosis reduced kidney and liver injury after thoracic aortic surgery despite an increased body temperature of up to 28°C. This strategy may be useful to prevent AKI, liver dysfunction, the need for hemodialysis and multiple organ failure and could improve mid-term results.
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Affiliation(s)
- Satoshi Miyamoto
- 1 Department of Clinical Engineering, Hiroshima University Hospital, Hiroshima, Japan
| | - Shinya Takahashi
- 2 Department of Cardiovascular Surgery, Hiroshima University Hospital, Hiroshima, Japan
| | - Shigeyuki Okahara
- 3 Department of Clinical Engineering, Junshin Gakuen University, Fukuoka, Japan
| | - Hidenobu Takahashi
- 1 Department of Clinical Engineering, Hiroshima University Hospital, Hiroshima, Japan
| | - Keijiro Katayama
- 2 Department of Cardiovascular Surgery, Hiroshima University Hospital, Hiroshima, Japan
| | - Masazumi Watanabe
- 2 Department of Cardiovascular Surgery, Hiroshima University Hospital, Hiroshima, Japan
| | - Kazuki Maeda
- 2 Department of Cardiovascular Surgery, Hiroshima University Hospital, Hiroshima, Japan
| | - Seimei Go
- 2 Department of Cardiovascular Surgery, Hiroshima University Hospital, Hiroshima, Japan
| | - Shohei Morita
- 2 Department of Cardiovascular Surgery, Hiroshima University Hospital, Hiroshima, Japan
| | - Tatsuya Kurosaki
- 2 Department of Cardiovascular Surgery, Hiroshima University Hospital, Hiroshima, Japan
| | - Bagus Herlambang
- 4 Department of Cardiovascular Surgery, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Taijiro Sueda
- 2 Department of Cardiovascular Surgery, Hiroshima University Hospital, Hiroshima, Japan
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Pacini D. Re: Low-flow lower body perfusion for spinal protection in a frozen elephant trunk simulation model. Eur J Cardiothorac Surg 2016; 50:971. [PMID: 27242358 DOI: 10.1093/ejcts/ezw193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Davide Pacini
- Department of Cardiac Surgery, S.Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
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Haldenwang PL, Häuser L, Prochnow N, Ziebura D, Baumann A, Sikole M, Schlömicher M, Schmitz I, Christ H, Strauch JT. Low-flow lower body perfusion for spinal protection in a frozen elephant trunk simulation model. Eur J Cardiothorac Surg 2016; 50:963-970. [DOI: 10.1093/ejcts/ezw146] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 03/16/2016] [Indexed: 11/13/2022] Open
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Organprotektion in der Chirurgie der thorakalen Aorta. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2015. [DOI: 10.1007/s00398-015-0030-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Mesenterialischämie bei selektiver Hirnperfusion. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2014. [DOI: 10.1007/s00398-013-1034-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Karhausen J, Stafford-Smith M. The role of nonocclusive sources of acute gut injury in cardiac surgery. J Cardiothorac Vasc Anesth 2013; 28:379-91. [PMID: 24119676 DOI: 10.1053/j.jvca.2013.04.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Indexed: 12/16/2022]
Affiliation(s)
- Jörn Karhausen
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina.
| | - Mark Stafford-Smith
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
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Luehr M, Bachet J, Mohr FW, Etz CD. Modern temperature management in aortic arch surgery: the dilemma of moderate hypothermia. Eur J Cardiothorac Surg 2013; 45:27-39. [PMID: 23628950 DOI: 10.1093/ejcts/ezt154] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Arch surgery is undoubtedly among the most technically and strategically challenging endeavours in aortic surgery, requiring thorough understanding not only of cardiovascular physiology, but also in particular, of neurophysiology (cerebral and spinal cord), and is still associated with significant mortality and morbidity. In the late 1980s, when deep hypothermic circulatory arrest (HCA) had gained widespread acceptance as the standard approach for arch surgery, antegrade selective cerebral perfusion (SCP), as an adjunct to deep HCA, began its triumphal march, offering excellent neuroprotection and improved overall outcome. This encouraged the use of antegrade SCP in combination with steadily increasing body core temperatures--a trend culminating in the progressive advocation of moderate-to-mild temperatures up to 35 °C, and even normothermia. The impetus for progressive temperature elevation was the limitation of adverse effects of profound hypothermia and the most welcome side effect of significantly shorter cooling and rewarming periods on cardiopulmonary bypass (CPB), and thereby, potentially, the alleviation of the systemic inflammatory response and, in particular, the risk of severe postoperative bleeding (and other organ dysfunctions). The safe limits of prolonged distal circulatory arrest, particularly with regard to the ischaemic tolerance of the viscera and the spinal cord, have not yet been clearly defined. Adverse outcomes due to inappropriate temperature management (core temperatures too high for the required duration of distal arrest) are probably highly underreported. Complications historically associated with hypothermia, namely excessive bleeding, are possibly overestimated. Trading effective neuroprotection and excellent outcomes for the risk of prolonged 'warm' distal ischaemia might constitute a significant step back, jeopardizing visceral and, in particular, spinal cord integrity, with unpredictable consequences for long-term outcome and quality of life, particularly affecting those in need of more complex surgery or with previous neurological deficits.
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Affiliation(s)
- Maximilian Luehr
- Department of Cardiac Surgery, Leipzig Heart Center - University of Leipzig, Leipzig, Germany
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Czerny M, Bachet J, Bavaria J, Bonser RS, Borger MA, De Paulis R, DiBartolomeo R, Grabenwoger M, Lonn L, Loubani M, Mestres CA, Schepens MAAM, Weigang E, Carrel TP. The future of aortic surgery in Europe. Eur J Cardiothorac Surg 2012; 43:226-30. [DOI: 10.1093/ejcts/ezs413] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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