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Surgical repair of ascending aortic and arch aneurysms with cerebral antegrade perfusion

Authors: Bockeria L.A., Mironenko V.A., Garmanov S.V.

Company:
Bakoulev National Medical Research Center for Cardiovascular Surgery, Ministry of Health of the Russian Federation, Rublevskoe shosse, 135, Moscow, 121552, Russian Federation

E-mail: Сведения доступны для зарегистрированных пользователей.

Heading: Original Research

UDC: 616.132.13-007.64-089:612.824

Link: Clinical Physiology of Blood Circulaiton. 2019; 4 (3): 239-249

Quote as: Bockeria L.A., Mironenko V.A., Garmanov S.V. Surgical repair of ascending aortic and arch aneurysms with cerebral antegrade perfusion. Cardiovascular Surgery News. 2019; 3 (4): 239–49 (in Russ.).

Keywords:  aortic arch prosthetics antegrade cerebral perfusion unilateral perfusion bigemispheral perfusion hypothermia

Received / Accepted:  28.11.2019/03.12.2019

Full text:  


Abstract

Objective. To study the issues tangential indications and benefits of unilateral or bihemispheric antegrade cerebral perfusion of the brain, as well as necessary and sufficient for protection of the body and brain, level of hypothermia.

Material and methods. This study included 111 patients with simultaneous intervention on the ascending and aortic arch, in which antegrade cerebral perfusion. The analysis of the results of preoperative measurement of the blood flow along the medullary artery with a modified Matas sample allowed to assess the functional closure of the Willis circle and determine the indications for safe unilateral or bigemispheral antegrade cerebral perfusion. Advanced intraoperative neuromonitoring, including invasive measurement of the acid-base state of venous blood, measurement of liquor pressure, transcranial dopplerography and cerebral oximetry allowed to control the adequacy of blood supply to the brain with a particular chosen strategy of brain protection and, if necessary, to change the strategy. Results. Evaluation of postoperative complications revealed the advantages of the use of unilateral antegrade cerebral perfusion, as well as moderate hypothermia (25 °C) compared with deep hypothermia (18 °C). The conducted factor analysis to identify the risk of neurological deficiency revealed the main factors-baseline hypertension and temporary operational parameters – the duration of artificial blood circulation, aortic compression and cerebral perfusion.

Conclusions. Antegrade cerebral perfusion provides adequate brain blood supply at the aorta arch replacement. Unilateral perfusion can be safely performed in cases of functionally closed Willis circle. Bigemisferal perfusion is indicated for patients with middle cerebral artery blood flow deficiency and with a functionally open Willis circle.

References

  1. Di Eusanio M., Schepens M.A., Morshuis W.J., Dossche K.M., Di Bartolomeo R., Pacini D. et al. Brain protection using antegrade selective cerebral perfusion: a multicenter study. Ann. Thorac. Surg. 2003; 76 (4): 1181–9. DOI: 10.1016/s0003- 4975(03)00824-5
  2. Minatoya K., Ogino H., Matsuda H., Sasaki H., Tanaka H., Kobayashi J. et al. Evolving selective cerebral perfusion for aortic arch replacement: high flow rate with moderate hypothermic circulatory arrest. Ann. Thorac. Surg. 2008; 86 (6): 1827–31. DOI: 10.1016/j.athoracsur.2008.07.024
  3. Khaladj N., Shrestha M., Meck S., Peterss S., Kamiya H., Kallenbach K. et al. Hypothermic circulatory arrest with selective antegrade cerebral perfusion in ascending aortic and aortic arch surgery: a risk factor analysis for adverse outcome in 501 patients. J. Thorac. Cardiovasc. Surg. 2008; 135: 908–14. DOI: 10.1016/j.jtcvs.2007.07.067
  4. Strauch J.T., Spielvogel D., Lauten A. Technical advances in total aortic arch replacement. Ann. Thorac. Surg. 2004; 77: 581–90. DOI: 10.1016/s0003-4975(03)01342-0
  5. Yoshimasa M., Naotaka M., Kei S., Seijiro Y. Axillary artery cannulation improves operative results for acute type A aortic dissection. Ann. Thorac. Surg. 2005; 80: 77–83. DOI: 10.1016/j.athoracsur.2005.01.058
  6. De Paulis R., Czerny M., Weltert L., Bavaria J., Borger M.A., Carrel T.P. et al. Current trends in cannulation and neuroprotection during surgery of the aortic arch in Europe. Eur. J. Cardiothorac. Surg. 2015; 47 (5): 917–23. DOI: 10.1093/ejcts/ezu284
  7. Li B., Hu X., Wang Z. The neurologic protection of unilateral versus bilateral antegrade cerebral perfusion in aortic arch surgery with deep circulatory arrest: a study of 77 cases. Int. J. Surg. 2017; 40: 8–13. DOI: 10.1016/j.ijsu.2017.02.023
  8. Малашенков А.И., Русанов Н.И., Быкова В.А., Рычин С.В., Айтелиев А.E., Яковлев С.Е., Имаев Т.Э. Проблемы защиты головного мозга при операциях на дуге аорты. Вестник Российской академии медицинских наук. 2005; 4: 21–5.[Malashenkov A.I., Rusanov N.I., Bykova V.A., Rychin S.V., Ayteliev A.E., Yakovlev S.E., Imaev Т.Е. Problems of brain protection in aortic arch operations. Annals of the Russian Academy of Medical Sciences. 2005; 4: 21–5 (in Russ.).]
  9. Белов Ю.В., Степаненко A.Б., Кузнечевский Ф.В. Непосредственные и отдаленные результаты хирургического лечения аневризм и расслоений восходящего отдела и дуги аорты. Российский кардиологический журнал. 2004; 9 (5): 5–17. [Belov Y.V., Stepanenko A.B., Kuznechevskiy F.V. Immediate and long-term results of surgical treatment of aneurysms and dissections of the ascending and the aortic arch. Russian Journal of Cardiology. 2004; 9 (5): 5–17 (in Russ.).]
  10. Константинов Б.А., Белов Ю.В., Кузнечевский Ф.В. Аневризмы восходящего отдела и дуги аорты. М.: АСТ; 2006.[Konstantinov B.A., Belov Y.V., Kuznechevskiy F.V. Aneurysms of the ascending aorta and the aortic arch. Мoscow; 2006 (in Russ.).]
  11. Estrera A.L., Miller C.M., Madisetty J. Ascending and transverse aortic arch repair. The impact of retrograde cerebral perfusion. Circulation. 2008; 118: 160–6. DOI:10.1161/circulationaha.107.757419
  12. Leshnower B.G., Myung R.J., Kilgo P.D., Vassiliades T.A., Vega J.D., Thourani V.H. et al. Moderate hypothermia and unilateral selective antegrade cerebral perfusion: a contemporary cerebral protection strategy for aortic arch surgery. Ann. Thorac. Surg. 2010; 90 (2): 547–54. DOI: 0.1016/j.athoracsur.2010.03.118
  13. Patel H.J., Deeb G.M. Ascending and arch aorta: pathology, natural history, and treatment. Circulation. 2008; 118 (2):188–95. DOI: 10.1161/circulationaha.107.690933
  14. Chen Y.C., Hsu R.B. Aortic surgery requiring hypothermic circulatory arrest in octogenarians. J. Formos Med. Assoc. 2008; 107 (5): 412–8. DOI: 10.1016/s0929-6646(08)60107-2 15. Minatoya K., Ogino H., Matsuda H., Sasaki H., Tanaka H., Kobayashi J. et al. Is conventional aortic arch surgery justifiable in octogenarians? J. Thorac. Cardiovasc. Surg. 2010; 139 (3): 641–5. DOI: 10.1016/j.jtcvs.2009.11.008
  15. Okada S., Kaneko T., Ezure M., Satoh Y., Hasegawa Y., Okonogi S., Takihara H. Total aortic arch replacement for aortic aneurysm in a 91-year-old man: report of a case. Kyobu Geka. 2010; 63 (10): 899–902.
  16. Olsson C., Thelin S. Antegrade cerebral perfusion with a simplified technique: unilateral versus bilateral perfusion. Ann. Thorac. Surg. 2006; 81 (3): 868–74. DOI: 10.1016/j.athoracsur. 2005.08.079
  17. Immer F.F., Moser B. Arterial access through the right subclavian artery in surgery of the aortic arch improves neurologic outcome and mid-term quality of life. Ann. Thorac. Surg. 2008; 85: 1614–8. DOI: 10.1016/j.athoracsur.2007.11.027
  18. Hagl C., Khaladj N., Karck M., Kallenbach K., Leyh R., Winterhalter M., Haverich A. Hypothermic circulatory arrest during ascending and aortic arch surgery: the theoretical impact of different cerebral perfusion techniques and other methods of cerebral protection. Eur. J. Cardiothorac. Surg. 2003; 24 (3): 371–8. DOI: 10.1016/s1010-7940(03)00337-3
  19. Spielvogel D., Mathur M., Griep R. Aneurysm of the aortic arch. In: Cohn L., Edmunds H. (Eds). Cardiac surgery in the adult. New York: McGraw-Hill; 2003: 1149–68.
  20. Strauch J.T., Spielvogel D., Lauten A. Optimal temperature for selective cerebral perfusion. J. Thorac. Cardiovasc. Surg. 2005; 130: 74–82. DOI: 10.1016/j.jtcvs.2004.08.041
  21. Kazui T., Yamashita K., Washiyama N. Aortic arch replacement using selective cerebral perfusion. Ann. Thorac. Surg. 2007; 83: 796–8. DOI: 10.1016/j.athoracsur.2006.10.082
  22. Zierer A., Aybek T., Risteski P., Dogan S., Wimmer-Greinecker G., Moritz A. Moderate hypothermia (30 °C) for surgery of acute type A aortic dissection. Thorac. Cardiovasc. Surg. 2005; 53 (2): 74–9. DOI: 10.1055/s-2004-830458
  23. Usui A., Oohara K., Murakami F., Ooshima H., Kawamura M., Murase M. Body temperature influences regional tissue blood flow during retrograde cerebral perfusion. J. Thorac. Cardiovasc. Surg. 1997; 114: 440–7. DOI: 10.1016/s0022-5223(97)70192-2
  24. Bakhtiary F., Dogan S., Zierer A., Dzemali O., Oezaslan F., Therapidis P. et al. Antegrade cerebral perfusion for acute type A aortic dissection in 120 consecutive patients. Ann. Thorac. Surg. 2008; 85 (2): 465–9. DOI: 10.1016/j.athoracsur.2007.10.017
  25. Harrington D.K., Walker A.S., Kaukuntla H. Selective antegrade cerebral perfusion attenuates brain metabolic deficit in aortic arch surgery: a prospective randomized trial. Circulation. 2004; 110: 231–6. DOI: 10.1161/01.cir.0000138945.78346.9c
  26. Bachet J., Guilmet D., Goudot B., Dreyfus G.D., Delentdecker P., Brodaty D., Dubois C. Antegrade cerebral perfusion with cold blood: a 13-year experience. Ann. Thorac. Surg. 1999; 67 (6): 1874–91. DOI: 10.1016/s0003-4975(99)00411-7
  27. Küçüker S.A., Ozatik M.A., Sarita 5 s A., Ta 5 sdemir O. Arch repair with unilateral antegrade cerebral perfusion. Eur. J. Cardiothorac. Surg. 2005; 27 (4): 638–43.
  28. Dossche K.M., Schepens M.A., Morshuis W.J., Muysoms F.E., Langemeijer J.J., Vermeulen F.E. Antegrade selective cerebral perfusion in operations on the proximal aorta. Ann. Thorac. Surg. 1999; 67: 1904–10. DOI: 10.1016/j.ejcts.2005.01.026
  29. Safi H.J., Miller C.C. 3rd, Estrera A.L., Huynh T.T., Porat E.E., Allen B.S., Sheinbaum R. Staged repair of extensive aortic aneurysms: long-term experience with the elephant trunk technique. Ann. Surg. 2004; 240 (4): 677–84. DOI: 10.1097/ 01.sla.0000140756.30517.1b
  30. Goldman S., Sutter F., Ferdinand F., Trace C. Optimizing intraoperative cerebral oxygen delivery using noninvasive cerebral oximetry decreases the incidence of stroke for cardiac surgical patients. Heart Surg. Forum. 2004; 7 (5): 376–81. DOI: 10.1532/hsf98.20041062
  31. Kim M.B., Ward D.S., Cartwright C.R., Kolano J., Chlebowski S., Henson L.C. Estimation of jugular venous O2 saturation from cerebral oximetry or arterial O2 saturation during isocapnic hypoxia. J. Clin. Monit. Comput. 2000; 16: 191–9. DOI: 10.1023/a:1009940031063
  32. Orihashi K., Sueda T., Okada K., Imai K. Near-infrared spectroscopy for monitoring cerebral ischemia during selective cerebral perfusion. Eur. J. Cardiothorac. Surg. 2004; 26: 907–11. DOI: 10.1016/j.ejcts.2004.06.014
  33. Kirkpatrick P.J., Lam J., Al-Rawi P., Smielewski P., Czosnyka M. Defining thresholds for critical ischemia by using nearinfrared spectroscopy in the adult brain. J. Neurosurg. 1998; 89: 389–94. DOI: 10.3171/jns.1998.89.3.0389
  34. Liu N., Sun L.Z., Chang Q., Yang J.G. Clinical application of cerebral oxygenation monitoring during aortic aneurysm operation. Zhonghua Yi Xue Za Zhi. 2007; 87 (15): 1030–3.
  35. Soeda M. Antegrade selective cerebral perfusion combined with deep hypothermic circulatory arrest on cerebral circulation: comparison between pulsatile and nonpulsatile blood flows. Ann. Thorac. Cardiovasc. Surg. 2007; 13.
  36. Kiziltan H.T., Baltali M., Koca D. Reduced jugular venous oxygen saturation during rewarming from deep hypothermic circulatory arrest: cerebral overextraction? Cardiovasc.Surg. 2003; 11: 213–7. DOI: 10.1016/s0967-2109(03)00005-x
  37. Arrowsmith J.E., Grocott H., Reves J.G. Central nervous system complications of cardiac surgery. Br. J. Anaesth. 2000; 84: 378–93. DOI: 10.1093/oxfordjournals.bja.a013444
  38. Toyama M., Matsumura Y., Tamenishi A., Okamoto H. Safety of mild hypothermic circulatory arrest with selective cerebral perfusion. Asian Cardiovasc. Thorac. Ann. 2009; 17 (5): 500–4. DOI: 10.1177/0218492309342716
  39. Pacini D., Leone A., Di Marco L., Marsilli D., Sobaih F., Turci S. et al. Antegrade selective cerebral perfusion in thoracic aorta surgery: safety of moderate hypothermia. Eur. J. Cardiothorac. Surg. 2007; 31: 618–22. DOI: 10.1016/j.ejcts.2006.12.032
  40. Bachet J. What is the best method for brain protection in surgery of the aortic arch? Selective antegrade cerebral perfusion. Cardiol. Clin. 2010; 28 (2): 389–401. DOI: 10.1016/j.ccl.2010.01.014
  41. Malvindi P.G., 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 (5): 891–7. DOI: 10.1510/icvts.2008.184184

About Authors

Leo A. Bockeria, Dr. Med. Sc., Professor, Academician of RAS and RAMS, President, orcid.org/0000-0002-6180-2619 Vladimir A. Mironenko, Dr. Med. Sc., Professor, Head of Department of Reconstructive Surgery and Aortic Root, orcid.org/0000-0003-1533-6212 Sergey V. Garmanov, Junior Researcher, Cardiovascular Surgeon, orcid.org/0000-0001-8568-9043

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