Comparison of Unilateral Antegrade Cerebral Perfusion at 16°C and 22°C Systemic Temperature
Objectives: Unilateral antegrade cerebral perfusion can be performed with minimal manipulations to arch arteries, but whether it provides adequate brain perfusion remains unclear. Some authors believe that this technique can be inadequate without deep hypothermia. We investigated the reliability of unilateral cerebral perfusion at 22°C hypothermia and the advantages of avoiding deep hypothermia.
Methods: Study participants were 55 patients who underwent surgery with unilateral cerebral perfusion. Patients were divided into 2 groups; 18 patients underwent surgery at 16°C hypothermia (group I) and 37 patients at 22°C hypothermia (group II). The mean age of the patients was 59 ± 10 years in group I and 55 ± 14 years in group II. Supracoronary ascending aorta replacement was performed in 25 and hemiarch replacement in 15 patients. Nine patients underwent surgery for a Bentall procedure. Total arch replacement was performed in 4 patients and total thoracic aorta replacement in 2 patients.
Results: The hospital mortality was 11% in group I and 5.4% in group II (P = .59). Transient neurologic deficits were not detected in any of the patients. The rate of permanent neurologic deficits was 5.9% in group I and 2.8% in group II (P = .54). Although mean aortic cross-clamp and antegrade cerebral perfusion times were not significantly different, mean cardiopulmonary bypass time was longer in group I than group II (174 ± 38 vs 142 ± 37 minutes, P = .005). Postoperative bleeding, blood product usage, serum creatinine and hepatic enzyme level changes, inotrope usage, and arrhythmia occurrence were not different between the 2 groups. Mean mechanical ventilation time was longer in group I than group II (24 ± 17 vs 16 ± 6 hours, P = .02).
Conclusions: Unilateral antegrade cerebral perfusion at 22°C systemic hypothermia appears to be safe and reliable for brain protection. Advantages of this technique are avoidance of deep hypothermia and reduced cardiopulmonary bypass and mechanical ventilation times in patients undergoing aortic surgery.
Apostolakis E, Akinosoglou K. 2008. The methodologies of hypothermic circulatory arrest and of antegrade and retrograde cerebral perfusion for aortic arch surgery. Ann Thorac Cardiovasc Surg 14:138-48.nBakhtiary F, Dogan S, Zierer A, et al. 2008. Antegrade cerebral perfusion for acute type A aortic dissection in 120 consecutive patients. Ann Thorac Surg 85:465-9.nDossche KM, Schepens MAAM, Morshuis WJ, Muysoms FE, Langemeijer JJ, Vermeulen FEE. 1999. Antegrade selective cerebral perfusion in operations on the proximal thoracic aorta. Ann Thorac Surg 67:1904-10.nHagl C, Ergin MA, Galla JD, et al. 2001. Neurologic outcome after ascending aorta-aortic arch operations: effect of brain protection technique in high-risk patients. J Thorac Cardiovasc Surg 121:1107-21.nHarrington DK, Lilley JP, Rooney SJ, Bonser RS. 2004. Nonneurologic morbidity and profound hypothermia in aortic surgery. Ann Thorac Surg 78:596-601.nHarrington DK, Fragomeni F, Bonser RS. 2007. Cerebral perfusion. Ann Thorac Surg 83:S799-804.nImmer FF, Moser B, Krähenbühl ES, et al. 2008. 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 85:1614-8.nKamiya H, Hagl C, Kropivnitskaya I, et al. 2007. The safety of moderate hypothermic lower body circulatory arrest with selective cerebral perfusion: a propensity score analysis. J Thorac Cardiovasc Surg 133:501-9.nKaneda T, Saga T, Onoe M, et al. 2005. Antegrade selective cerebral perfusion with mild hypothermic systemic circulatory arrest during thoracic aortic surgery. Scand Cardiovasc J 39:87-90.nKazui T, Yamashita K, Washiyama N, et al. 2002. Usefulness of antegrade selective cerebral perfusion during aortic arch operations. Ann Thorac Surg 74:S1806-9.nKucuker S, Ozatik MA, Saritas A, Tasdemir O. 2005. Arch repair with unilateral antegrade cerebral perfusion. Eur J Cardiothorac Surg 27:638-43.nMalvindi PG, Scrascia G, Vitale N. 2008. Is unilateral antegrade cerebral perfusion equivalent to bilateral cerebral perfusion for patients undergoing aortic arch surgery? Interact Cardiovasc Thorac Surg 7:891-7.nMerkkola P, Tulla H, Ronkainen A, et al. 2006. Incomplete circle of Willis and right axillary artery perfusion. Ann Thorac Surg 82:74-9.nOlsson C, Thelin S. 2006. Antegrade cerebral perfusion with a simplified technique: unilateral versus bilateral perfusion. Ann Thorac Surg 81:868-74.nPanos A, Murith N, Bednarkiewicz M, Khatchatourov G. 2006. Axillary cerebral perfusion for arch surgery in acute type A dissection under moderate hypothermia. Eur J Cardiothorac Surg 29:1036-40.nPapantchev V, Hristov S, Todorova D, et al. 2007. Some variations of the circle of Willis, important for cerebral protection in aortic surgery-a study in Eastern Europeans. Eur J Cardiothorac Surg 31:982-9.nSanioglu S, Sokullu O, Yapici F, et al. 2007. Axillary artery cannulation in surgery of the ascending aorta and the aortic arch. Turk Gogus Kalp Damar Cerrahisi Dergisi 15:197-201.nTasdemir O, Saritas A, Kucuker S, Ozatik MA, Sener E. 2002. Aortic arch repair with right brachial artery perfusion. Ann Thorac Surg 73:1837-42.nUrbanski PP, Lenos A, Blume JC, et al. 2008. Does anatomical completeness of the circle of Willis correlate with sufficient cross-perfusion during unilateral cerebral perfusion? Eur J Cardiothorac Surg 33:402-8.nZierer A, Aybek T, Risteski P, Dogan S, Wimmer-Greinecker G, Moritz A. 2005. Moderate hypothermia (30°C) for surgery of acute type A aortic dissection. Thorac Cardiovasc Surg 53:74-9.n
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