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Ann Thorac Surg 1995;59:393-397
© 1995 The Society of Thoracic Surgeons

Retrograde Cerebral Perfusion: Clinical Experience in Emergency and Elective Aortic Operations

Cardiothoracic Surgical Unit, and Department of Anaesthesia, Queen Elizabeth Hospital, Birmingham, United Kingdom

Accepted for publication September 22, 1994.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
We recently have used retrograde cerebral perfusion via the superior vena cava in association with hypothermic circulatory arrest as an adjunct to cerebral protection during aortic arch operations. Between April 1993 and March 1994, 23 patients (14 male; 9 female; median age, 64 years; age range, 25 to 76 years; 14 emergency, 9 elective) underwent operation on the ascending aorta, aortic arch, or both for acute dissection (11) or aneurysm (12). Aortic root replacement was performed in 13 patients (7 with arch replacement), ascending aortic replacement in 7 (4 with arch replacement), isolated aortic arch replacement in 2, and repair of sinus of Valsalva aneurysm in 1. Coronary artery bypass grafting was performed in 4 patients. Hypothermic circulatory arrest (15°C) and retrograde cerebral perfusion were implemented in all cases (median circulatory arrest time, 21 minutes; range, 13 to 51 minutes; median retrograde cerebral perfusion time, 20 minutes; range, 12 to 50 minutes). Three hospital deaths occurred (atheromatous embolic stroke, sepsis, rupture of infrarenal aortic aneurysm). The remaining patients had no neurologic damage (median intensive therapy unit stay, 1 day; range, 1 to 5 days). Retrograde cerebral perfusion is easy to establish and safe, and may improve brain protection during hypothermic circulatory arrest.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
See also page 397.

Surgical repair of the ascending and arch segments of the aorta for aneurysmal disease or dissection is facilitated by using the ``open'' distal anastomosis technique and deep hypothermic circulatory arrest (HCA). Although during the short period of circulatory arrest depression of cerebral metabolism by anesthesia and deep hypothermia ameliorate cerebral injury, the optimal level of hypothermia and the safe duration of the circulatory arrest remain controversial. A period of cerebral ischemia exceeding 45 minutes is associated with a higher incidence of stroke, whereas circulatory arrest periods exceeding 65 minutes are associated with increased mortality [1]. This restriction has led to development of adjunctive techniques to augment cerebral protection during HCA, such as retrograde cerebral perfusion (RCP) through the superior vena cava (SVC). Preliminary clinical reports have demonstrated the feasibility and the safety of this technique [2–7]. We report our recent clinical experience and describe our simple technique of implementing RCP.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Patients
This report details 23 patients undergoing operation on the ascending aorta, the aortic arch, or both between April 1993 and March 1994. It represents a consecutive series of cases requiring hypothermic circulatory arrest. There were 14 male and 9 female patients (median age, 64 years; range, 26 to 76 years). Indications for operation were acute type A aortic dissection in 11 patients, aneurysm of the ascending aorta and aortic arch in 10, infected pseudoaneurysm at the site of previous root replacement in 1, and aneurysm of sinus of Valsalva with SVC fistula in association with a large patent ductus arteriosus in 1. The operative procedures included aortic root replacement with coronary artery reimplantation in 13 patients, replacement of the ascending aorta in 7, isolated aortic arch replacement in 2, and closure of patent ductus arteriosus and sinus of Valsalva aneurysm repair in 1. A number of concomitant procedures were performed, and these included partial aortic arch replacement in 5 patients, total aortic arch replacement in 6 (5 with elephant trunk procedure), and coronary artery bypass grafting in 4. A summary of patients' details and type of operation performed is illustrated in Tables 1 and 2.

View larger version (22K): [in this window] [in a new window]   Fig 1. . Cannulation for cardiopulmonary bypass and retrogade cerebral perfusion. The retrograde line is primed and clamped (clamps A and B). (IVC = inferior vena cava; LA = left atrium; LV = left ventricle; RV = right ventricle; SVC = superior vena cava.)

During cooling, mobilization of the aorta was undertaken. The aorta then was clamped and myocardial protection was achieved by antegrade infusion of 1 L of crystalloid cardioplegia solution (St. Thomas I) and topical cooling. A further instillation of antegrade cardioplegia was employed after coronary reimplantation both for myocardial protection and as an anastomotic integrity check. Myocardial temperature was not monitored. A snare was placed around the SVC cannula. At a nasopharyngeal temperature of 15°C the circulation was arrested. Ice packs then were placed around the head, the arterial cannula was clamped, and the blood was drained into the bypass reservoir. The SVC was isolated from the venous circulation and the clamp from the parallel arterial line was removed. Venous drainage from the IVC was allowed throughout. Retrograde cerebral perfusion then was commenced with flow adjusted to maintain a left jugular bulb pressure around 25 mm Hg, measured by a dedicated single-lumen left retrograde internal jugular venous cannula isolated from drug infusions (Fig 2). Flow rates of 300 to 700 mL/min were achieved with this method. Effluent blood at the head vessel ostia was returned to the reservoir by suction from within the open aortic arch.

View larger version (22K): [in this window] [in a new window]   Fig 2. . Retrograde cerebral perfusion through the superior vena cava (SVC). (IVC = inferior vena cava; LA = left atrium; LV = left ventricle; RV = right ventricle.)

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Three postoperative deaths (13%) occurred in patients requiring emergency operations. In 1 patient with megaaorta syndrome and unstable angina due to a critical left main coronary artery stenosis who underwent replacement of the aortic root and arch and coronary artery bypass grafting, a postoperative computed tomographic scan showed multiple cerebral infarcts. At operation, the aneurysmal aortic arch and the carotid ostia contained confluent friable atheroma. Inevitably, suturing and surgical manipulation within the field led to extensive fragmentation. In this patient death occurred because of embolic stroke despite RCP and the precautions. The second patient presented in extremis with an infected pseudoaneurysm at the site of previous aortic root and hemiarch replacement with a valved conduit. He underwent replacement of the infected graft with a homograft aortic root and additional homograft aortic segment to achieve partial arch replacement. He awoke from the operation neurologically intact but died of persistent sepsis and renal failure on the 28th postoperative day. The third patient died 5 days after uncomplicated replacement of the aortic root and ascending aorta for acute type A dissection of rupture of an infrarenal aortic aneurysm. Two patients suffered transient postoperative confusion, which resolved spontaneously within 12 hours after extubation. The remaining patients awoke neurologically intact from the operation and suffered no complications. Details of bypass, HCA times, and RCP times are illustrated in Table 2. The median stay in the intensive therapy unit was 1 day (range, 1 to 5 days). All survivors have been followed up (median, 6 months; range, 1 to 13 months) and are in New York Heart Association class I or II.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
In this report we describe our recent experience using retrograde cerebral perfusion in association with HCA for the treatment of complex aortic disease. Despite the widespread use of HCA in aneurysm operations the optimal level of hypothermia and the safe duration of the circulatory arrest are not settled. Clinical experience suggests that when the duration of HCA is less than 45 minutes at temperatures of 15° to 20°C, a lower incidence of neurologic complications is recorded [1]. Stroke and mortality rates are increased with longer periods of circulatory arrest [1, 8]. As complex aortic procedures may require longer periods of circulatory arrest, a number of strategies have been advocated to increase the safety limit of HCA. These include treatment with barbiturates [9], corticosteroids, and oxygen free radical scavengers [7] before institution of HCA; use of alpha-stat pH control during cooling and rewarming [10]; slow rate of cooling [11]; avoidance of hyperglycemia [12]; and intraoperative EEG monitoring [13]. More recently, retrograde cerebral perfusion through the SVC has been introduced as a method to enhance cerebral protection during HCA. It was first described to treat cerebral air embolism during cardiopulmonary bypass [14], and has since been used with HCA in the treatment of complex aortic disease in a limited number of patients. Different methods of implementing RCP have been described. Generally, oxygenated blood is returned to the SVC during HCA, and venous drainage to the pump reservoir is obtained by returning the blood draining from the neck vessels, and venting the heart. In all these reports the IVC is clamped [4–7], and an experimental study has suggested improved cerebral protection when clamping the IVC [15]. We establish RCP by means of bicaval cannulation and by connecting the SVC cannula to a line in parallel with the arterial return. After isolation of the SVC cannula from the venous circuit, we commence retrograde flow and leave the IVC cannula unclamped. This would appear to be associated with two practical advantages: first, there is a reduction in the amount of blood returning from the descending aorta and this results in a clearer operative field, and second, it allows continuous venous drainage, facilitating the maintenance of uninterrupted RCP. Allowing venous drainage from the IVC also reduces the use of suction, and this may reduce the incidence of blood cellular damage. We do not find it necessary to cannulate the femoral vein instead of the IVC [3]. Continuous lower body perfusion has been used by some authors [2, 4], but this may increase pooling of blood in the surgical field.

All the published series to date using RCP have reported a good clinical outcome and absence of RCP-related complications. No retrograde perfusion-related complications occurred in our patients. Three deaths occurred in patients requiring longer bypass and aortic clamp times. However, scrutiny of our results shows that all three deaths were, in fact, due to events unrelated to the length of the procedure.

Although RCP may enhance cerebral protection during HCA, this has not been substantiated. Different mechanisms of protection have been postulated. These include the possibility of optimizing metabolic function by providing oxygen and removing catabolic products [5, 6], keeping constant and even cooling of the brain, and flushing microemboli from the arterial tree before reintroduction of antegrade perfusion [7]. Clear demonstration of any of these mechanisms is lacking. Significant oxygen extraction assessed by comparing the oxygen content of the blood infused retrogradely through the SVC and the carotid artery effluent during RCP [5, 6] has led to the assumption that the brain oxygen demands during hypothermia may be met. This is based on the assumption that blood retrogradely perfused through the SVC does, indeed, reach the cerebral tissue, and that the lower oxygen content in the carotid artery effluent blood results from cerebral tissue rather than generalized upper body extraction. All the reported series, including ours, comment on the cerebral outcome of the patients undergoing RCP, but two important considerations should be made. First, the mean circulatory arrest time in these series is within the limits considered safe when using HCA alone, and second, no study has yet performed preoperative and postoperative cognitive and neurologic assessment.

Although further studies are necessary to ascertain if RCP does improve cerebral protection during HCA, we conclude that RCP is ``safe'' and can be easily implemented by adopting a modification of the normal cardiopulmonary bypass circuit.

	Acknowledgments

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
We thank the Department of Clinical Perfusion of the Queen Elizabeth Hospital, Birmingham, for their collaboration in designing the retograde cerebral perfusion circuit.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Address reprints requests to Mr Bonser, Cardiothoracic Surgical Unit, Queen Elizabeth Hospital, Edgbaston, Birmingham B15 2TH, UK.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 

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This Article Abstract Correction (v60,p234) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Domenico Pagano John A. Carey Ramesh L. Patel Simon M. Allen Robert S. Bonser Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Pagano, D. Articles by Bonser, R. S. Search for Related Content PubMed PubMed Citation Articles by Pagano, D. Articles by Bonser, R. S. Related Collections Related Article