The Transcranial Doppler Sonography for Optimal Monitoring and Optimization of Cerebral Perfusion in Aortic Arch Surgery: A Case Series
Objective: To analyze the feasibility and advantages of transcranial doppler sonography (TCD) for monitoring and optimization of selective cerebral perfusion (SCP) in aortic arch surgery.
Methods: From April 2013 to April 2014, nine patients with extensive aortic pathology underwent surgery under moderate hypothermic cardiac arrest with unilateral antegrade SCP under TCD monitoring in our institution. Adequate sonographic window and visualization of circle of Willis were to be confirmed. Intraoperatively, a cerebral cross-filling of the contralateral cerebral arteries on the unilateral SCP was to be confirmed with TCD. If no cross-filling was confirmed, an optimization of the SCP was performed via increasing cerebral flow and increasing PCO2. If not successful, the SCP was to be switched to bilateral perfusion. Air bubble hits were recorded at the termination of SCP.
Results: A sonographic window was confirmed in all patients. Procedural success was 100%. The mean operative time was 298 ± 89 minutes. Adequate cross-filling was confirmed in 8 patients. In 1 patient, inadequate cross-filling was detected by TCD and an optimization of cerebral flow was necessary, which was successfully confirmed by TCD. There was no conversion to bilateral perfusion. Extensive air bubble hits were confirmed in 1 patient, who suffered a postoperative stroke. The 30-day mortality rate was 0.
Conclusion: The TCD is feasible for cerebral perfusion monitoring in aortic surgery. It enables a confirmation of adequacy of cerebral perfusion strategy or the need for its optimization. Documentation of calcific or air-bubble hits might add insight into patients suffering postoperative neurological deficits.
Doblar DD. 2004. Intraoperative transcranial ultrasonic monitoring for cardiac and vascular surgery. Semin Cardiothorac Vasc Anesth 8:127-45.
Estrera AL, Garami Z, Miller CC 3rd, et al. 2005. Cerebral monitoring with transcranial Doppler ultrasonography improves neurologic outcome during repairs of acute type A aortic dissection. J Thorac Cardiovasc Surg 129:277-85.
Ghazy T, Darwisch A, Schmidt T, et al. 2016. Transcranial Doppler sonography for optimization of cerebral perfusion in aortic arch operation. Ann Thorac Surg 101:e15-6.
Okita Y, Miyata H, Motomura N, Takamoto S, et al. 2015. A study of brain protection during total arch replacement comparing antegrade cerebral perfusion versus hypothermic circulatory arrest, with or without retrograde cerebral perfusion. J Thorac Cardiovasc Surg 149:S65-73.
Rasulo FA, De Peri E, Lavinio A. 2008. Transcranial Doppler ultrasonography in intensive care. Eur J Anaesthesiol Suppl 42:167-73.
Urbanski P, Lenos A, Kolowca M, et al. 2013. Near-infrared spectroscopy for neuromonitoring of unilateral cerebral perfusion. Eur J Cardiothorac Surg 43:1140-4.
van der Linden J, Casimir-Ahn H. 1991. When do cerebral emboli appear during open heart operations? A transcranial doppler study. Ann Thorac Surg 51:237-41.
Yeh T Jr, Austin EH 3rd, Sehic A, Edmonds HL Jr. 2003. Rapid recognition and treatment of cerebral air embolism: the role of neuromonitoring. J Thorac Cardiovasc Surg 126:589-91.
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