Giant Aneurysm After Aortic Coarctation: Repair without Circulatory Arrest
2
Citation
12
Reference
10
Related Paper
Citation Trend
Abstract:
Abstract We describe the case of a 23-year-old patient presenting for redo aortic arch surgery because of recoarctation and poststenotic aneurysm formation after patch aortoplasty in infancy. Using the hemi-clamshell approach, the entire aortic arch was replaced and the supraaortic branches were reimplanted. The applied surgical technique using hypothermic extracorporeal circulation without cardiac arrest allowed an uninterrupted cerebral and spinal cord perfusion due to stepwise clamping of the aortic arch during reconstruction and resulted in an excellent neurologic outcome at six-month follow-up. (J Card Surg 2010;25:560-562)Keywords:
Extracorporeal circulation
ObjectiveTo observe the influence of various methods of cerebral protection during deep hypothermic circulatory arrest(DHCA) on S-100 protein.MethodsEighteen dogs were randomly and equally divided into three groups:the deep hypothermic circulatory arrest(DHCA group),the DHCA with retrograde cerebral perfusion(DHCA+RCP group),and the DHCA with intermittent antegrade cerebral perfusion(DHCA+IACP group).Upon interruption of cardiopulmonary bypass(CPB),the nasopharyngeal temperature was slowly lowered to 18℃,before CPB was discontinued for 90 minutes,after 90 minutes,CPB was re-established and the body temperature was gradually restored to 36℃,then CPB was terminated.Before the circulatory arrest,45min,90min after the circulatory arrest and 15min,30min after re-established of CPB,blood samples were drawn from the jugular veins for assay of S-100 protein.Upon completion of surgery,the dogs was sacrificed and the hippocampus was removed from the brain,properly processed for examination by transmission electron microscope for changes in the ultrastructure of the brain and nerve cells.ResultsThere was no significant difference in the content of S-100 protein before circulatory arrest among all three groups(P0.05).After circulatory arrest,DHCA and DHCA+RCP group showed an significant increase in the content of S-100 protein(P0.01).There was no significant difference in the content of S-100 protein after circulatory arrest in DHCA+IACP group.ConclusionCerebral ischemic injuries would occur if the period of DHCA is prolonged.RCP during DHCA would provide protection for the brain to some extent,but it is more likely to cause dropsy in the brain and nerve cells.On the other hand IACP during DHCA appears to provide better brain protection.
Cite
Citations (0)
Cite
Citations (0)
Surgical therapy for aortic arch disease usually requires a period of hypothermic circulatory arrest, which calls for cerebral protection strategies and adjuncts. The optimal strategy for protecting the brain from irreversible ischaemic damage during the period of circulatory arrest remains controversial. Patients present with diverse aortic pathologies and this may dictate different cerebral protection methods that are tailored for the circumstances of each individual case. The purpose of this overview is to describe each method of cerebral protection employed in hemi-aortic arch surgery and to explain their advantages and disadvantages. A surgical case on hemi-aortic arch replacement using retrograde cerebral perfusion is demonstrated (Video 1). We also present our hospital demographics and outcomes pertaining to cerebral protection in hemi-aortic arch surgery.
Video 1
Cerebral protection in hemi-aortic arch surgery
The current practices employed for brain protection during aortic arch surgery include: (I) deep hypothermic circulatory arrest (DHCA); (II) retrograde cerebral perfusion (RCP); and (III) selective antegrade cerebral perfusion (SACP).
Cite
Citations (7)
Objectives: Open surgery for aortic arch diseases consists of aortic arch replacement with vascular prostheses requiring cardiopulmonary bypass and deep hypothermic circulatory arrest. This technique is associated with significant morbidity and mortality rates, mainly due to neurological complications and the sequelae of deep hypothermic circulatory arrest. Less invasive surgical aortic arch techniques have thus been developed. It is currently unclear which revascularisation technique and which stent-graft device is the best for the individual patient. This issue was the focus of our study.
Cite
Citations (0)
Correction of ascending aorta and proximal aortic arch pathology with numerous surgical techniques having been proposed over the years remains a surgical challenge. This study was undertaken to identify risk factors influencing outcome after aortic arch operations, requiring deep hypothermic circulatory arrest (DHCA).Between 1993 and 2010, 207 consecutive patients were operated for ascending aorta and proximal arch correction with the use of deep hypothermic circulatory arrest with retrograde cerebral perfusion. All patients were followed up with regular out-patient clinics, transthoracic echocardiography and, when required, chest computed tomography.There were 102 (49.3%) emergencies (acute type A dissection) and 105 (50.7%) elective cases. Mean age: 63.5 ± 12 years. Mean circulatory arrest time was 25.4 ± 13 min. Unadjusted analysis of factors associated with 30-day mortality revealed emergency status, preoperative hemodynamic instability, acute dissection, reoperation, increased circulatory arrest time, postoperative bleeding, postoperative creatinine levels and presence of neurological dysfunction. Multi-adjusted analysis revealed duration of circulatory arrest as the only and main factor related to death. Thirty-day mortality was 2.4% for the elective and 7.2% for emergencies cases. Survival during long-term follow-up was 93, 82 and 53% at 1, 5 and 10 years, respectively.Ascending aorta and proximal aortic arch replacement with brief duration of deep hypothermic circulatory arrest combined with retrograde cerebral perfusion is a safe method with acceptable short- and long-tem results.
Thoracic aorta
Cite
Citations (24)
Background With evolutions in technique, recent data encourage the use of cerebral perfusion during aortic arch repair. However, a randomized data have demonstrated higher rates of neurologic injury according to MRI lesions using antegrade cerebral perfusion during hemiarch reconstruction. Methods This was a retrospective review of two institutional aortic center databases to identify adult patients who underwent aortic hemiarch reconstruction for elective aortic aneurysm or acute type A aortic dissection. Patients were stratified according to cerebral protection method: (1) deep hypothermic circulatory arrest (DHCA) group versus (2) DHCA/retrograde cerebral perfusion (RCP) group. Results A total of 320 patients and 245 patients underwent hemiarch reconstruction for aortic aneurysm electively and aortic dissection, respectively. In aneurysmal pathology, the DHCA group included 133 patients and the DHCA/RCP group included 187 patients. Operative mortality was 0.8% in the DHCA group and 2.7% in the DHCA/RCP group (p = 0.41). Kaplan–Meier survival estimates revealed comparable 2-year survival (p = 0.14). In dissection, 43 patients and 202 patients were included in the DHCA group and the DHCA/RCP group, respectively. Operative mortality was equivalent between the two groups (11.6% in the DHCA group and 9.4% in the DHCA/RCP group, p = 0.58). Long-term survival was similar at 2 years between the groups (p = 0.06). Multivariable analysis showed cerebral perfusion strategy was not associated with the composite outcome of operative mortality and stroke. Conclusions In treating both elective and acute ascending aortic pathologies with hemiarch reconstruction, both DHCA alone or in combination with RCP yield comparable results.
Stroke
Cite
Citations (6)
Objective To observe and evaluate the effects of the deep hypothermic circulatory arrest(DHCA) and regional cerebral perfusion(RCP) in pediatric aortic arch surgery.Methods According to different methods of CPB,70 infants less than 3-month-old with CoA or IAA were undergone corrective surgery with DHCA or RCP.The bypass time,aortic clamp time,DHCA or RCP time,ventilation time,ICU stay time and post-operative complications were recorded and compared between two groups.Results The incidence of neurological complications was significantly higher in DHCA group.The CPB time was significantly longer in the RCP group,and the RCP time was significantly longer than DHCA time.Blocking time,ventilator intubation time,ICU residence time,postoperative renal dysfunction,low cardiac output,puhnonary inflammation and hospital mortality was no significant difference between the two groups.Conclusion RCP is an effective cerebral protection technique.Compared with DHCA,RCP works better in sustained brain cerebral perfusion and is suitable for complex aortic arch operation in children.It has a better effort in protection of the neurological system than DHCA.
Key words:
Aortic arch Cardiac surgical procedures ; Cardiopulmonar bypass ; Deep hypothermic circulatory arrest ; Regional cerebral perfusion
Interrupted aortic arch
Aortic cross-clamp
Cite
Citations (0)
Techniques for Retrograde Cerebral Perfusion in the Treatment of Aortic Lesions via Left Thoracotomy
Retrograde cerebral perfusion under deep hypothermic circulatory arrest is a simple and useful adjunct in aortic surgery and is performed by many surgeons in the treatment of aortic arch pathology. In recent years, this technique has been recommended in the surgery of distal arch and proximal descending aortic lesions through a left thoracotomy inclusion. The aim of the technique is to increase the right atrial pressure for retrograde cerebral perfusion. After cooling using femorofemoral bypass, circulatory arrest is initiated. The right atrial pressure is increased to 20 mmHg, and retrograde cerebral circulation results. In this article, five patients with distal aortic arch and proximal descending thoracic aortic lesions who were operated on by using this technique were evaluated. It is suggested that this technique can be used with a lateral thoracotomy approach that is suitable for procedures on a distal aortic arch and proximal descending aorta.
Thoracotomy
Descending aorta
Thoracic aorta
Retrograde perfusion
Cite
Citations (2)
Objective
To compare the cerebral injuries of antegrade cerebral perfusion among deep, moderate or mild hypothermic circulatory arrest in surgical patients of coarctation of the aorta aged under 3 years and to evaluate the severity of cerebral injury enzyme indicators with antegrade cerebral perfusion and deep hypothermic circulatory arrest.
Methods
Retrospective analyses were conducted for 60 surgical children of coarctation of the aorta aged under 3 years from January 2012 to January 2017 and 20 controls with ventricular septal defect. And the severity of cerebral injury was evaluated by neuron-specific enolase (NSE) and S100 protein.
Results
The levels of NSE in children with antegrade cerebral perfusion and deep hypothermic circulatory arrest were significantly higher(P<0.05)than those with moderate/mild hypothermic circulatory arrest and control group during DHCA/ACP ending, CPB ending, 3 h and 12 h postoperatively; the level of S100 protein in children with antegrade cerebral perfusion and deep hypothermic circulatory arrest were significantly higher(P<0.05)than those with moderate/mild hypothermic circulatory arrest and control group during CPB ending, 3 h and 12 h postoperatively.
Conclusions
Severity of cerebral injury with antegrade cerebral perfusion and deep hypothermic circulatory arrest may be higher than that with moderate/mild hypothermic circulatory arrest.
Key words:
Deep hypothermic circulatory arrest; Antegrade Cerebral Perfusion; Cerebral injury
Cite
Citations (0)
Is deep hypothermic circulatory arrest inferior to antegrade cerebral perfusion for brain protection
Objective This study aims to compare the deep hypothermic circulatory arrest (DHCA) and antegrade cerebral perfusion (ACP) with moderate hypothermia for cerebral protection during aortic arch surgery. Background Aortic arch surgery is a complicated technical operation due to the risk of cerebral insults and the need for cerebral protection. Materials and methods Forty patients performed aortic arch surgery with cerebral protection either by, DHCA (18°C) in 20 patients and ACP (22 °C) in the others. Data were collected including; preoperative risks factors, intraoperative finding and postoperative neurological examination and brain computed tomography (CT)when indicated. Results Neurological insults were higher in ACP group (30%) than in DHCA group (10%) without statistical significance. Cardiopulmonary bypass (CPB) time was lower in DHCA group (133.05 ± 28.04) than in ACP group (177.65 ± 53.3), and significantly p-value is ( Conclusion Techniques for cerebral protection (DHCA or ACP)during aortic arch surgery have no statistical significant difference, and each technique has its own advantages and disadvantages.
Aortic surgery
Cite
Citations (0)