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Ann Thorac Surg 2000;70:1472-1477
© 2000 The Society of Thoracic Surgeons

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Original articles: cardiovascular

Cerebral complications associated with selective perfusion of the arch vessels

^a Department of Cardiovascular Surgery, School of Medicine, Keio University, Tokyo, Japan

Address reprint requests to Dr Ueda, Department of Cardiovascular Surgery, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku-ku 160-8582 Tokyo, Japan

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. Few studies have determined risk factors for postoperative cerebral complications associated with surgery of the aortic arch using selective cerebral perfusion.

Methods. Between November 1992 and December 1998, 113 patients underwent aortic arch repair combined with selective cerebral perfusion. For each patient, three arch vessels were perfused using a single roller pump at a rectal temperature of 23°C.

Results. Among the 108 patients who underwent postoperative neurologic assessment, 25 patients (23%) suffered from cerebral complications. Five patients (5%) suffered from transient neurologic disturbance and 17 patients (16%) suffered from stroke, and 7 patients (7%) of the preceding 17 patients had residual neurologic disturbance upon discharge. Three patients (3%) with either preoperative coma (n = 1) or post bypass cardiac arrest (n = 2) sustained severe global cerebral dysfunction. The occurrence of cerebral complications was not related to cerebral perfusion time. Independent risk factors for cerebral complications included a history of cerebrovascular disease, perioperative shock, distal anastomosis below the left pulmonary artery, malperfusion of extremities, and older age (> 60 years).

Conclusions. Although high-level brain function was well preserved in most patients, the incidence of stroke when using current selective cerebral perfusion techniques is still high.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
Brain damage associated with repair of the aortic arch is a disastrous complication that not only may lead to operative death but always worsens a patient’s quality of life. At present, deep hypothermic circulatory arrest with or without retrograde cerebral perfusion and selective cerebral perfusion are two methods commonly used for brain protection. Because there are no completely randomized comparative studies that have been performed, it remains to be determined which method more effectively prevents postoperative cerebral complications.

Using selective cerebral perfusion, we have been studying optimal cerebral perfusion flow rate and attempting to improve perfusion techniques [1–4]. To date, few studies have determined risk factors for cerebral complications associated with surgery of the aortic arch using selective cerebral perfusion.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
Between November 1992 and December 1998, in 113 of 114 consecutive patients (75 males, 38 females, mean age ± standard deviation [SD]; 63 ± 13 years) undergoing aortic arch repair, selective cerebral perfusion was used (Tables 1 and 2). Aside from the patients that were treated on an emergency basis, each patient was screened as much as possible for preoperative computed tomography, magnetic resonance imaging, and magnetic resonance angiography of the brain for cerebrovascular diseases.

Cardiopulmonary bypass circuit included a centrifugal pump and a membrane oxygenator plus heat exchanger, while the arterial line was bifurcated for the femoral artery and for antegrade perfusion through the ascending aorta or a branch of the graft. A second arterial line equipped with an air filter was used for selective perfusion of the arch vessels using a roller pump. The end of the line was trifurcated, and then connected to the perfusion catheters, which had a balloon and a pressure monitor line in their tip (15F for the brachiocephalic artery, 12F for the left common carotid and the left subclavian artery, Sumibe Medical Co, Tokyo, Japan). A protein-impregnated Dacron polyester fabric graft was used. Whenever a total arch replacement was indicated, three small grafts for each arch vessel and one for antegrade perfusion were attached to the main graft before use.

The patients were placed in a supine position for replacement of the ascending aorta and aortic arch, and a median sternotomy was performed. Whenever exposure was insufficient for distal anastomosis, a T-shaped thoracotomy through the third or fourth intercostal space was added. In most cases, the skin incision was extended to include the left supraclavicular fossa to expose the arch vessels, and tourniquets were placed around each vessel. Although, in most patients, the arterial line was placed in the femoral artery, the main perfusion route was instituted through a cannula in either the ascending aorta or the right subclavian artery whenever the distal aorta was found to contain mural thrombi. A two-stage venous cannula in the right atrium was used in most of the previously mentioned patients.

Following institution of total cardiopulmonary bypass, cooling of the patient began. The left vent catheter was then indwelled through the right superior pulmonary vein. Myocardial protection was obtained by antegrade perfusion of either crystalloid or blood cardioplegic solution. After initiation of circulatory arrest at a rectal temperature of less than 23°C, the aortic arch was opened and the three arch vessels were severed in an en bloc fashion. A perfusion catheter was inserted into the left subclavian artery, and then gently secured using the tourniquet (after the balloon had been inflated and leakage around the catheter had ceased). After backflow from the left common carotid and brachiocephalic artery was observed, cannulation into these vessels was done in the same manner. The perfusion flow rate was initially maintained at 10 mL/min/kg, and subsequently adjusted so as to ensure the perfusion pressure measured at the tip of the catheter in the left common carotid artery was consistently between 40 and 60 mm Hg.

At first, distal aortic anastomosis was performed. Following completion of the anastomosis, any debris or air in the descending aorta was evacuated by retrograde perfusion through the femoral cannula, while antegrade perfusion was established through a branch graft. In most patients, anastomosis and unclamping of the left subclavian artery, proximal aorta, left common carotid artery, and brachiocephalic artery were performed in this order. Rewarming began during anastomosis of the brachiocephalic artery.

For patients whose disease had extended from either the ascending aorta or the proximal arch to the descending aorta below the left pulmonary artery, the patient was placed in a right semi-decubitus position and the table was rotated to facilitate surgical procedures both through a median sternotomy and through a left thoracotomy. Because the descending aorta was clamped during this operation, perfusion of the lower body was performed through the femoral cannula. The perfusion techniques and surgical procedures were basically the same as those previously described.

For patients whose disease extended from the distal arch to the descending aorta, where the clamp could not be applied to the aorta between the left common carotid and left subclavian artery, the patient was placed in a right decubitus position and surgery was performed through a left thoracotomy. Venous drainage was obtained from a right atrial catheter inserted through the femoral vein and from a left atrial catheter inserted through the left atrial appendage. The femoral artery was used for the arterial line. When the rectal temperature was less than 23°C, circulatory arrest was achieved using a clamp applied to the distal aorta. The distal arch was opened and selective perfusion of the three arch vessels was established. Distal perfusion was also reinstituted. Before completion of the proximal aortic anastomosis, the perfusion catheters were removed and evacuation of any air was carefully performed. Proximal perfusion was then instituted through a branch graft. Then distal aortic anastomosis was performed, and finally the left subclavian artery was anastomosed to the branch graft.

All patients with postoperative neurologic disturbance, regardless of severity, underwent brain computed tomography or magnetic resonance imaging, or both of these procedures. All patients were also referred to a neurologist. Postoperative cerebral complications were classified as follows:

1. Transient neurologic disturbance without any related focus in the brain: delayed awakening more than 24 hours, convulsion, delirium, or double vision.
   
2. Stroke: no or negligible neurologic disturbance upon discharge.
   
3. Stroke: residual neurologic disturbance upon discharge.
   
4. Severe global cerebral dysfunction.
   

Continuous data were expressed as mean ± standard deviation. Student’s t test was used for comparison of the means, and p values less than 0.05 were considered significant. Univariate analysis was performed using Fisher’s two-tailed exact test. When a variable with continuous data showed a significant p value on the t test, the cases were divided into two groups using a cutoff value at which the p value on the exact test was the lowest. Any variables showing a p value less than 0.1 on the exact test were included in multiple logistic regression analysis. All statistical analyses were performed using the SPSS statistical software program (SPSS Inc, Chicago, IL).

	Results

Top Abstract Introduction Material and methods Results Comment References

 
Early death occurred in 11 of 113 patients (10%), with neurologic diagnosis being impossible in five of these 11 patients because they died during or immediately after the operation. Therefore, the presence of postoperative cerebral complications was studied in the remaining 108 patients. Seventy-five patients were male, and 9 patients had Marfan’s syndrome (Table 2). Pathology revealed that 54 patients showed dissection, with 25 of these 54 being operated on during the acute stage (acute aortic dissection). Four patients sustained malperfusion of the extremities because of acute dissection. Twenty-seven patients had a history of prior aortic operation, and 15 of these 27 underwent reoperation. Emergency surgery was performed on 26 patients, including 12 patients with aortic ruptures (seven of these 12 patients were in a state of critical shock).

Thirteen patients had a history of cerebrovascular disease, including cerebral infarction in 10 patients and transient ischemic attacks in 2 patients; the remaining patient went into a coma as a result of acute dissection. Preoperative brain computed tomography was carried out in 65 patients (Table 3), and old cerebral infarctions were detected in 24 of these 65 patients. Magnetic resonance imaging performed in 53 patients revealed old infarctions including lacunae in 42 patients. Among the 45 patients undergoing preoperative magnetic resonance angiography, 15 had either occlusive or aneurysmal disease of cervicocerebral vessels, which included bilateral common and internal carotid arteries, vertebral arteries, and intracranial vessels. Preoperative radiologic analysis of the brain could not be performed in 32 patients.

The main arterial route was the ascending aorta in 37 patients, the right subclavian artery in 8 patients, and the femoral artery in the remaining 68 patients (Table 2). Whereas three arch vessels were selectively perfused in 87 patients, the left subclavian artery could not be perfused in the remaining 21 patients for various reasons, including one case where the perfusion catheter had readily come off the artery.

The cardiopulmonary bypass time, aortic cross-clamp time, selective cerebral perfusion time, and distal circulatory arrest time (n = 91) were 255 ± 68 minutes, 152 ± 48 minutes, 127 ± 52 minutes, and 66 ± 23 minutes, respectively (Table 1). Rectal temperature at the beginning of and at the end of selective cerebral perfusion was 23.5°C ± 2.4°C and 27.5°C ± 3.9°C, respectively. There was a wide range of rectal temperatures, mainly caused by patient-to-patient variations in the time required for rewarming. The high rectal temperature at the beginning of selective cerebral perfusion was attributed to the rapid institution of the perfusion of the arch vessels in patients with preoperative shock or in patients with ostial stenosis of the arch vessels. The rectal temperature at the end of selective cerebral perfusion was high when reattachment of the brachiocephalic artery had taken a long time. Following cessation of the bypass, 3 patients went into cardiac arrest caused by right atrial rupture, ventricular tachyarrhythmia, or cardiac tamponade, and thus required cardiopulmonary resuscitation.

Postoperative cerebral complications occurred in 25 patients (23%), (see Table 4) : class 1 in 5 patients, class 2 in 10 patients, class 3 in 7 patients, and class 4 in 3 patients. Among the 3 patients in class 4, one went into a coma preoperatively and subsequently died on postoperative day 14, whereas the remaining 2 patients were among the previously mentioned 3 patients who had experienced catastrophic shock after cessation of bypass, and thus required cardiopulmonary resuscitation. A watershed type of infarction was noted in 4 patients of 25 (16%). The age of patients showing postoperative cerebral complications (67 ± 9 years) was higher than that of those without (61 ± 14 years, p < 0.05), (Table 1). However, no difference was observed in cardiopulmonary bypass time, aortic cross-clamp time, selective perfusion time, distal circulatory arrest time, or body temperature at any point in time.

Factors showing a p value of less than 0.1 on Fisher’s exact test were subjected to multiple logistic regression analysis that determined five independent risk factors for postoperative cerebral complications (Table 2). These factors included a history of cerebrovascular disease (odds ratio = 14.0), perioperative shock (odds ratio = 10.5), distal anastomosis below the left pulmonary artery (odds ratio = 7.9), malperfusion of the extremities (odds ratio = 22.2), and older age (odds ratio = 4.8).

	Comment

Top Abstract Introduction Material and methods Results Comment References

 
Before 1992, we perfused two arch vessels (the brachiocephalic and left common carotid artery) in order to ensure brain protection [5]. Since 1992, we have performed a novel procedure involving perfusion of all three arch vessels with no clamp technique and a deeper state of hypothermia than previously used. Perfusion flow rate in all three vessels was established based on the results of our previous studies [1–4]. In the present series, the incidence of postoperative cerebral complications was 23%, whereas that of permanent disability (classes 3 and 4) was 9%. However, we concluded that the occurrence of class 4 brain damage was not attributable to selective cerebral perfusion itself.

Ergin and colleagues [6] reported that of 183 patients who had operations using hypothermic circulatory arrest, temporary neurologic disturbances occurred in 19% of all patients and strokes in 11%. In Okita and colleagues [7], of 148 patients undergoing arch repair using hypothermic circulatory arrest with retrograde cerebral perfusion, delirium occurred in 25% of all patients, and strokes in 4%.

In the previous three reports, including our own, the age of the patient and the rate of emergency surgery were nearly equal. Although the rate of total arch replacement was higher in our series (78%) than in either Ergin and colleagues’ [6] (29%) or in Okita and colleagues’ [7] (42%), it was not a risk factor for cerebral complications in any of these reports. The incidence of stroke (classes 2 and 3) was highest in our series (16%). This might, at least in part, be caused by cannulation of the arch vessels. On the other hand, it follows that the incidence of stroke due to emboli in retrograde cerebral perfusion would have been low, given that the procedure was performed to counteract the brain embolism associated with cardiopulmonary bypass [8]. Furthermore, when arch repair required only a short amount of time, retrograde cerebral perfusion in most cases resulted in an excellent outcome [9].

However, some studies have found that retrograde cerebral perfusion contributed little to brain metabolism [10, 11]. In addition, temporary neurologic disturbances, such as delirium, were believed to have resulted from inadequate cerebral protection [6]. Whereas Okita and colleagues [7] concluded that there was no relationship between delirium and duration of circulatory arrest associated with retrograde cerebral perfusion, Reich and colleagues [12] reported that a late disturbance of memory and fine motor function occurred in patients showing circulatory arrest for longer than 25 minutes. We found no relationship between selective cerebral perfusion time and the incidence of postoperative cerebral complications. To preserve high-level brain function, it is essential to maintain adequate cerebral metabolism during surgery. Therefore, we believe it is appropriate to maintain antegrade cerebral perfusion.

A history of cerebrovascular disease was the most significant risk factor for cerebral complications. In other studies where selective cerebral perfusion was not performed, Okita and colleagues [7] and Ergin and colleagues [6] did not list history of cerebrovascular disease as a risk factor for cerebral complications. On the other hand, Svensson and colleagues [13] did list it as a risk factor. Ohmi and colleagues [14] reported, as we did, that patients with cervicocerebral vascular disease are highly susceptible to stroke following selective cerebral perfusion. To date, no strategy has been established to manage such patients. In our study, the presence or absence of a preoperative radiologic examination did not affect the occurrence of postoperative cerebral complications.

The age of a patient, perioperative shock, and extension of the disease to the distal aorta reportedly has been associated with postoperative cerebral complications [5, 7, 13]. In patients with an aneurysm involving the descending thoracic aorta, an extended arteriosclerosis was related to the occurrence of stroke [6]. In terms of our procedures, positional changes during cerebral perfusion were necessary in cases in which replacement from the ascending to the descending aorta was necessary. In such a situation, accidental removal or kinking of the perfusion catheters occasionally occurred. In fact, among the 4 patients who sustained a watershed type infarction, 3 patients had undergone median sternotomy with an additional left thoracotomy. On the other hand, Ohmi and colleagues [14] observed that cerebral perfusion using a single pump caused an imbalance of cerebral blood distribution, and thus recommended use of two separate roller pumps. Furthermore, cerebral blood flow during open distal anastomosis was in some cases reduced when a certain amount of perfused blood leaked into the lower part of the body [15]. These findings demonstrated the necessity of monitoring perfusion flow rate through each catheter.

Malperfusion of the extremities associated with acute aortic dissection was also a risk factor. Although multiple arterial lines were prepared for these patients, the results suggested that malperfusion of the arch vessels may have occurred during cooling. Establishment of the selective perfusion of the arch vessels before initiation of the total cardiopulmonary bypass possibly prevents cerebral complications in these patients with malperfusion.

	References

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