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Ann Thorac Surg 1995;60:345-352
© 1995 The Society of Thoracic Surgeons
Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Abstract |
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Methods. A retrospective review of 156 patients undergoing elective and emergent operations of the thoracic aorta over the past 7 years was performed. Seventy-five patients underwent proximal aortic procedures: 22 with ascending aneurysms, 45 with type A dissections, and 8 with arch reconstructions. Eighty-one patients underwent descending thoracic or thoracoabdominal procedures: 26 with Crawford type I aneurysms, 18 with type II, 8 with type III, 8 with type IV, 11 with traumatic transections, and 10 with type B dissections. Outcomes measured were neurologic injury, renal failure, and mortality.
Results. For proximal aortic procedures, the stroke rate was 12% using cardiopulmonary bypass and 48% using hypothermic circulatory arrest. The addition of retrograde cerebral perfusion decreased the stroke rate to 0% (p < 0.01) and the mortality rate to 7.1% compared with 37% for hypothermic circulatory arrest (p < 0.05). For thoracic and thoracoabdominal aortic operations, straight cross-clamping resulted in a 27% rate of spinal cord injury and a 24% rate of renal failure, whereas the addition of distal aortic bypass resulted in a statistically significant reduction (p < 0.01) in neurologic injury to 7% and a notable, but not statistically significant, decrease in renal failure to 13%. Distal aortic bypass also reduced the mortality rate from 22% to 7% (p < 0.05).
Conclusions. Retrograde cerebral perfusion decreases the stroke rate and mortality rate in proximal aortic operations and distal aortic perfusion decreases the rates of neurologic injury, renal failure, and mortality in thoracoabdominal aortic operations.
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Introduction |
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Over the past decade, many innovations in circulation management technique during thoracic aortic reconstruction have been developed. For the management of proximal aortic disease and acute type A dissection, the classic technique has entailed aortic cross-clamping at the level of the innominate artery with subsequent repair of the ascending aortic pathology. More recently, authors have advocated an ``open'' distal anastomosis for reconstruction of acute type A dissection with simultaneous use of hypothermic circulatory arrest (HCA). Additionally, HCA has been used for aneurysmal disease involving the aortic arch as well as extension of aortic dissection tears into the aortic arch [1–7]. Others have advocated the use of selective antegrade cerebral perfusion during open arch operations [8]. Retrograde cerebral perfusion (RCP) originally was described for the management of inadvertent massive air embolism during cardiac operations [9]. It first was used for cerebral protection during aortic arch operations by Ueda and associates [10]. Retrograde cerebral perfusion currently is being widely investigated in animal models and clinically [11–15]. In fact, some have advocated total body retrograde perfusion during proximal aortic operations [16, 17].
Advances in circulation management for thoracic and thoracoabdominal aortic reconstruction likewise have provided the surgeon many options. These have included straight aortic cross-clamping, cerebrospinal fluid (CSF) drainage, and various pharmacologic manipulations to decrease the incidence of spinal cord paraplegia by increasing spinal cord perfusion pressure and altering the reperfusion injury [18]. More recently many authors have advocated the routine use of distal aortic perfusion via an extracorporeal circuit to provide additional protection against ischemia in all organ systems distal to the aortic cross-clamp [19–21]. Even more recently, the use of hypothermic circulation management techniques during descending thoracic aortic operation has been advocated [22].
This study is a retrospective review comparing the efficacy of several major circulation management strategies used during proximal and distal aortic reconstruction. Techniques used during proximal aortic repair include (1) straight cross-clamping of the distal ascending aorta, (2) HCA, and (3) HCA with RCP. Techniques used during distal aortic repair include (1) straight aortic cross-clamping and (2) distal aortic perfusion.
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Material and Methods |
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TopAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Proximal Aortic Reconstruction
The proximal aortic group comprised 75 patients: 22 with ascending aneurysms, 45 with type A dissections, and 8 with arch aneurysms (Table 1
). Patients were divided further based on the specific operation performed. The proportion of emergent cases, as defined by operation within 12 hours of urgent nonscheduled admission, also was determined. Outcomes were evaluated in terms of clinically evident cerebrovascular accident and 60-day mortality in the proximal aortic group. Data were evaluated by standard 
2 statistical analysis.
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). Outcomes were expressed in rates of spinal neurologic injury (paraplegia/paraparesis), renal failure as defined by an increase in serum creatinine level 2.0 mg/dL above preoperative levels or initiation of dialysis, and 60-day mortality.
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The retrograde cerebral perfusion circuit (Fig 1) consisted of standard bicaval cannulation (Research Medical, Midvale, UT) as well as femoral artery cannulation with 17F to 21F (Biomedicus, Minneapolis, MN) wire-wrapped cannulas. A 30F superior vena caval cannula was used intentionally in all patients to allow greater cephalad flow during the retrograde cerebral perfusion phase of the circulatory management. All hearts were vented via the right superior pulmonary vein. Patients were cooled for a minimum of 30 minutes to a nasopharyngeal temperature of 15°C. As soon as total body and cerebral temperatures were of appropriate level, the patient was exsanguinated and the cardiopulmonary bypass circuitry was converted into the RCP system. This consisted of taking the two clamps off the ``bridge'' between the venous and arterial lines and placing these clamps on the proximal venous line, the distal arterial line, and the inferior vena cava cannula. This allowed for direct blood flow from the arterial line through the ``bridge'' into the superior vena caval venous line retrograde and directly into the superior vena cava. Circuit clamping was controlled on the table by the surgeon. Central venous pressure (CVP) monitoring at the level of the jugular vein was used and RCP pressures were maintained at 20 mm Hg. Average flow was 400 mL/min with a range from 300 to 750 mL/min to target a CVP of 20 mm Hg. Using the retrograde cerebral perfusion technique, the aortic arch was opened and inspected, and dark blood was verified emanating from the brachiocephalic orifices. Temperature of inflow blood during retrograde cerebral perfusion was 10°C. The patient was placed into a slight Trendelenburg position during RCP.
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The patient then was rewarmed and the proximal aortic reconstruction was performed during rewarming. This would include placement of the proximal anastomosis, resuspension of an aortic valve during type A dissection, placement of an aortic valve for a ``Wheat'' procedure, or placement of a composite graft with coronary reimplantation.
CIRCULATION MANAGEMENT: THORACIC/THORACOABDOMINAL AORTIC RECONSTRUCTION.
Circulation management for thoracic and thoracoabdominal reconstruction consisted of two fundamental strategies: (1) straight cross-clamp and no distal perfusion and (2) distal perfusion, which in the majority of cases entailed a left atrial to distal aortic circuit. Since July 1, 1992, our protocol for thoracic and thoracoabdominal reconstruction also has included an initial CSF drainage catheter placed to right atrial pressure with the goal of maintaining CSF pressure less than 12 mm Hg.
For more extensive thoracoabdominal operations, a staged cross-clamp technique was used with segmental reconstruction of the aorta as necessary. For typical Crawford type II thoracoabdominal reconstruction, the conduct of the operation included the following segmental anastomoses in sequence: (1) the proximal anastomosis with intercostal reimplantation and appropriate ``bevel'' of the anastomosis, (2) reimplantation of the left renal artery to a 6-mm graft, (3) creation of the mesenteric patch establishing flow to the celiac, superior mesenteric, and right renal arteries, and (4) completion of the distal anastomosis or aorto--bifemoral graft as necessary (Fig 2). Moderate core cooling was used during distal perfusion to approximately 32°C. Upon completion of the mesenteric anastomosis, the patient was rewarmed to 37°C. Five thousand units of intravenous heparin was used routinely and the activated clotting time was titrated between 180 and 200 seconds. At the completion of the mesenteric anastomosis, the distal aortic perfusion apparatus was transferred to a preconstructed 8-mm side-arm graft off of the thoracic aortic portion of the graft for rewarming. This in essence unloaded the left ventricle during rewarming. Target goals for distal perfusion included a mean proximal arterial pressure of approximately 80 to 90 mm Hg and a mean distal arterial pressure of greater than 60 mm Hg. Intercostal arteries routinely were implanted or included in either the proximal or distal beveled portion of the anastomosis.
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Pharmacologic adjunctive management of these patients included administration of magnesium as well as methylprednisolone (125 mg) before cross-clamping. Mannitol was given just before removal of the cross-clamp.
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Results |
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TopAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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). Patients who died intraoperatively were excluded from calculation of stroke rates because of obvious inability to assess neurologic outcome. Stroke rates by circulatory techniques were as follows: straight cardiopulmonary bypass with cross-clamp, 12%; HCA, 48%; and RCP, 0%. Mortality rates by circulatory techniques were as follows: straight cardiopulmonary bypass with cross-clamp, 16%; HCA, 37%; hypothermia with RCP, 7%. Compared with HCA, RCP significantly lowered stroke rates (p < 0.01) and mortality (p < 0.05) (Table 4).
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Additionally, when looking at type A dissection alone, hypothermia with RCP, which was used in 9 patients, had a 0% stroke rate compared with a 50% stroke rate with HCA and a 20% stroke rate with ``classic'' distal ascending aortic cross-clamp without an open distal anastomosis.
Although the numbers were small, an additional 8 isolated aortic arch reconstructive procedures were performed. Five of these used HCA alone and the most recent three procedures used RCP. One HCA patient died intraoperatively and neurologic deficits developed in 2 of the other 4. The 3 RCP patients had no neurologic deficits.
Emergent operations, as would be expected, had a higher mortality rate than elective operations. Sixty-eight percent of all proximal aortic procedures were emergent, usually type A dissection (see Table 1
). The overall mortality rate for emergent proximal aortic reconstruction was 25.4% compared with 9.5% for elective cases (see Table 3).
Thoracic and Thoracoabdominal Reconstructions
For all thoracic and thoracoabdominal aortic operations (n = 81), the incidence of neurologic injury was 14%, renal failure 18%, and 60-day mortality 14% (Table 5). The percentage of emergency cases in this total group was 30.9% (see Table 2). ``Classic'' aortic cross-clamping resulted in a 27% incidence of spinal cord injury and a 24% renal failure rate. Circulation management using distal aortic perfusion resulted in a statistically significant reduction in neurologic deficit and 60-day mortality. Spinal cord paraplegia/paraparesis rates decreased from 27.2% to 6.7% (p < 0.01). Mortality decreased from 22.2% to 6.7% (p < 0.05). Distal aortic perfusion also resulted in a notable, but statistically not significant, decrease in renal failure from 24.2% to 13.3% (Table 6).
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Comment |
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TopAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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The first adjunct in circulation management of these patients consisted of the introduction of HCA [1]. Using HCA, many authors reported that patients with complex proximal aortic pathology could be repaired with relative safety; indeed, HCA was mandatory for arch repair. Despite this advance, mortality and major morbidity remained challenging. There also have been selected reports using antegrade perfusion strategies and separate cannulation of the carotid arterial systems for management of the cerebral circulation during aneurysm and dissection repair [8]. These circulation management schemes are quite effective but are technically cumbersome and possibly no more effective than HCA alone. In 1988, RCP was introduced clinically for reconstruction of proximal aortic pathology by Ueda and associates [10]. This method has been used by many others with success, and the optimum technical strategy for retrograde cerebral perfusion presently is evolving. There are some reports revealing that increased flow at high CVP is detrimental and other reports revealing that low flow with a low CVP or inadequate delivery of blood retrograde to the brain is likewise detrimental. Nojima and associates [26] suggested that RCP at 20 mm Hg is more effective than 10 mm Hg or 30 mm Hg.
As a result of multiple clinical reports over the past few years, this technique has been used by aortic surgeons with greater frequency. In our report we not only used RCP for three aortic arch reconstructions but also used this technique during repair of nine acute aortic dissections allowing for complete inspection of the aortic arch and open distal anastomosis with either simple anastomosis or ``hemiarch'' reconstruction. Our results were quite satisfactory, showing no strokes or transient neurologic deficits and only one death in this group, which occurred on postoperative day 10 of sudden ventricular fibrillation in an otherwise completely intact and alert 79-year-old woman. Our data corroborate the experimental data of Nojima and associates [26] showing RCP at a flow achieving a CVP of approximately 20 mm Hg in a slight Trendelenburg position is a safe circulation management technique during reconstruction of type A aortic dissection and arch aneurysm. This report also lends credence to the idea established more than a decade ago and adopted by more and more aortic surgeons that an open distal anastomosis is a preferred technique for repair of all acute type A aortic dissections [4].
As with proximal aortic surgery, the circulation management strategies during reconstruction of the thoracic and thoracoabdominal aorta also have evolved over the past decade. Distal aortic perfusion of various types is not a new idea. Arterial to arterial shunts, including the Gott shunt, have been recommended and used by many groups [19]. Although these have limitations, there also have been reports of excellent results with these measures. Likewise, left atrial to femoral artery bypass as well as femoral venous to femoral arterial bypass have been used successfully during reconstruction of the distal thoracic and thoracoabdominal aorta. However, Hollier and his group [27] have had excellent success using straight cross-clamping of the aorta modified with CSF drainage and pharmacologic manipulation of the reperfusion injury. Despite these data, more and more authors have been advocating the routine use of distal aortic perfusion methods during reconstruction of the thoracic and thoracoabdominal aorta. Borst and Cunninghamm have advocated the use of these techniques maintaining distal aortic perfusion pressures of greater than 60 mm Hg [28]. Safi and Bartoli [29] have shown that the combination of distal aortic perfusion with routine CSF drainage has resulted in a substantial improvement in paraplegia rates compared with controls from an earlier period when neither were used. With more complex thoracoabdominal aortic reconstruction, Fehrenbacher and colleagues [30] showed that ``staged'' segmental reconstruction of the aorta using left heart bypass resulted in very acceptable morbidity and mortality. Our data support the hypothesis that the distal aortic perfusion circuit maintaining a distal mean arterial pressure greater than 60 mm Hg improves paraplegia rates compared with straight aortic cross-clamping alone. Examination of our data from July 1, 1992, to present reveals 50 consecutive thoracic and thoracoabdominal aortic reconstructions with a 2% paraplegia rate. With this cohort of patients, routine adherence to the protocol in Figure 2 was performed, with distal aortic perfusion pressures of 60 mm Hg or greater, CSF drainage, moderate core cooling, intercostal reimplantation, and pharmacologic manipulation with magnesium, mannitol, and methylprednisolone. The only paraplegia in this group of patients was in a complete and total reconstruction of a Crawford type II thoracoabdominal aneurysm from the level of the subclavian artery into both common iliac arteries.
In summary, based upon this retrospective analysis of 156 patients we conclude that RCP is an effective circulation management strategy during the reconstruction of type A aortic dissection and aneurysmal disease involving the aortic arch. We believe that RCP flows should be maintained at a CVP of approximately 20 mm Hg. Broadening the use of RCP to type A dissections allows for a safe and effective open distal aortic anastomosis or hemiarch procedure as necessary with full inspection of the aortic arch. We also conclude that for thoracic and thoracoabdominal aortic reconstruction, distal aortic perfusion in conjunction with the above adjunctive measures has produced excellent results. Another subset of patients that would benefit from this circulation management would be those with transections of the thoracic aorta secondary to trauma where left atrial to femoral artery bypass without heparin has been our recent standard. There has been no incidence of paraplegia using this system, whereas straight aortic cross-clamping has produced paraplegia at our institution.
Retrograde cerebral perfusion and distal aortic perfusion in proximal and distal aortic reconstructive surgery provide protection against neurologic injury and reduce mortality. These circulatory management techniques are under current investigation and warrant extensive further laboratory investigation and clinical application.
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