CONTINUOUS RETROGRADE CEREBRAL PERFUSION DURING PROFOUND HYPOTHERMIC CIRCULATORY ARREST AT OPERATION FOR STANFORD TYPE A DISSECTING ANEURYSM
Yasushi SatohKYOUICHIROU TSUDAYOSHIROU HAMADASusumu IshikawaAkio OotakiYoshimi OotaniKazuhiro SakataHideaki IchikawaTooru TakahashiYasuo Morishita
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Abstract:
Three patients with chronic Stanford type A dissecting aneurysm were successfully operated upon using continuous retrograde cerebral perfusion (CRCP) during profound hypothermic circulatory arrest. Following profound hypothermic (14-15°C) circulatory arrest for 30-40 minutes, CRCP was started with a flow rate of 120-550ml/min to maintain a superior vena caval pressure of 15-20 mmHg. The circulatory arrest time was 56-101 minutes. The longer retrograde cerebral perfusion time induced prolonged wakefullness, but no serious neurological complications were encountered. In conclusion, CRCP is useful for cerebral protection during profound hypothermic circulatory arrest.Keywords:
Retrograde perfusion
To valuate cerebral protection by retrograde cerebral perfusion (RCP) via superior vena cava,the study results for the last ten years have been reviewed.RCP is regarded as an assistant method in deep hypothermic circulatory arrest(DHCA) in that it provides partial brain blood flow,maintains a low brain temperature,optimizes cerebral metabolic function during DHCA by supplying oxygen and some nutrient and removal of catabolic products;it also reduces the incidence of cerebral embolization by flushing out air and particulate microemboli from the arterial tree before the reinstitution of antegrade perfusion,thus prolonging the limitation of safety of DHCA.But brain edema probably happens to restrict the clinical use of this method.Some protecting drugs including cerebral protective fluid is in research and some progresses have been achieved,while inferior vena cava occlusion during RCP is still in research.Indications for RCP should be strictly identified and possibl risk should be prevented.
Cerebral edema
Retrograde perfusion
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Three patients with chronic Stanford type A dissecting aneurysm were successfully operated upon using continuous retrograde cerebral perfusion (CRCP) during profound hypothermic circulatory arrest. Following profound hypothermic (14-15°C) circulatory arrest for 30-40 minutes, CRCP was started with a flow rate of 120-550ml/min to maintain a superior vena caval pressure of 15-20 mmHg. The circulatory arrest time was 56-101 minutes. The longer retrograde cerebral perfusion time induced prolonged wakefullness, but no serious neurological complications were encountered. In conclusion, CRCP is useful for cerebral protection during profound hypothermic circulatory arrest.
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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
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Deep hypothermic circulatory arrest (DHCA) without retrograde cerebral perfusion (RCP) has a strict time limit. We modified a surgical technique for anastomosis to shorten the period of DHCA and unilateral cerebral perfusion (UCP).Between March 1993 and August 2001, retrospective analysis was done on 23 consecutive patients, who underwent aortic arch replacement with branches. The patients were divided into two groups: DHCA group and UCP group. The DHCA group, in which DHCA alone and without additional cerebral perfusion was performed, comprised of nine patients. Proximal aortic anastomosis was performed first during systemic cooling; then both the brachiocephalic artery and left carotid artery were reconstructed with the branches of the artificial graft during circulatory arrest; thereafter, cerebral and coronary perfusions were resumed. The UCP group, in which DHCA was not used but right hemisphere perfusion during deep hypothermia was performed when the origin of brachiocephalic artery was safely clamped, consisted of 14 patients.Mean time of DHCA was 18.8+/-4.2 minutes and that of right hemisphere perfusion time was 11.0+/-3.8 minutes, respectively. Twenty-one patients survived the surgery (91.3%), and two (8.7%) died during hospitalization. Transient cerebral complication occurred in four patients in the DHCA group and all recovered. Logistic regression analysis revealed that DHCA was the only parameter to significantly influence temporary neurological dysfunction. There was no other significant difference between the two groups.With our modified and simple surgical technique for aortic arch repair, we were able to successfully shorten the DHCA time and right hemisphere perfusion time. However, because DHCA was the only parameter to significantly influence temporary neurological dysfunction, some form of continuous cerebral perfusion at deep hypothermia may be a safer method to preserve cerebral function.
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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
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Retrograde cerebral perfusion technique has been used recently for the protection of the brain during circulatory arrest in aortic surgery. However, the safe time limit for retrograde cerebral perfusion has not been known. From July 1993 to April 1995, 20 patients underwent thoracic aortic operations using retrograde cerebral perfusion technique with hypothermic circulatory arrest. Retrograde cerebral perfusion was used to repair the aortic dissection in seventeen patients, aortic arch aneurysm in two patients and annuloaortic ectasia with severely calcified ascending aorta in one patient. The mean duration of retrograde cerebral perfusion was 74 minutes (19-135 min). There were six patients in whom retrograde cerebral perfusion exceeded 90 minutes, however no patients except one who had preoperative cerebral infarction showed any neurological deficits. There were two operative deaths and three hospital deaths, neither of which was related to postoperative neurological complications. Retrograde cerebral perfusion safely may provide a longer period of circulatory arrest at least up to 90 minutes.
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Abstract Background: Aortic arch surgery is impossible without the temporary interruption of brain perfusion and therefore is associated with high incidence of neurologic injury. The deep hypothermic circulatory arrest (HCA), in combination with antegrade or retrograde cerebral perfusion (RCP), is a well-established method of brain protection in aortic arch surgery. In this retrospective study, we compare the two methods of brain perfusion. Materials and Methods: From 1998 to 2006, 48 consecutive patients were urgently operated for acute type A aortic dissection and underwent arch replacement under deep hypothermic circulatory arrest (DHCA). All distal anastomoses were performed with open aorta, and the arch was replaced totally in 15 cases and partially in the remaining 33 cases. Our patient cohort is divided into those protected with antegrade cerebral perfusion (ACP) (group A, n = 23) and those protected with RCP (group B, n = 25). Results: No significant difference was found between groups A and B with respect to cardiopulmonary bypass-time, brain-ischemia time, cerebral-perfusion time, permanent neurologic dysfunction, and mortality. The incidence of temporary neurologic dysfunction was 16.0% for group A and 43.50% for group B (p = 0.04). The mean extubation time was 3.39 ± 1.40 days for group A and 4.96 ± 1.83 days for group B (p = 0.0018). The mean ICU-stay was 4.4 ± 2.3 days for group A and 6.9 ± 2.84 days for group B (p = 0.0017). The hospital-stay was 14.38 ± 4.06 days for group A and 19.65 ± 6.91 days for group B (p = 0.0026). Conclusion: The antegrade perfusion seems to be related with significantly lower incidence of temporary neurological complications, earlier extubation, shorter ICU-stay, and hospitalization, and hence lower total cost.
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Introduction Retrograde cerebral perfusion is used as an adjunct to deep hypothermic circulatory arrest (DHCA) for cerebral protection while dealing with complex aortic lesions. Patients and methods Sixty-six patients, operated for aneurysms of the aorta using DHCA, were studied. In 52 patients, retrograde cerebral perfusion was used as an adjunct to DHCA for cerebral protection. Forty patients were subjected to surgical correction of ascending aorta lesions, 10 were operated for ascending aorta and arch lesions, eight had distal arch aneurysm repair and eight had surgery for thoracoabdominal aortic aneurysms. Results Neurologic dysfunction was reported in 6% of patients. No neurologic complications were reported in any patient who had retrograde cerebral perfusion during the circulatory arrest period. Conclusion A major limitation of DHCA is the time constraint imposed, beyond which DHCA in isolation may not be safe. Considering the simplicity and safety involved, more liberal use of retrograde cerebral perfusion as an adjunct to DHCA is advocated.
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