Ascending and Transverse Aortic Arch Repair

Estrera, Anthony L.; Miller, Charles C.; Lee, Taek Yeon; Shah, Pallav; Safi, Hazim J.

doi:10.1161/circulationaha.107.757419

Cited by 85 publications

(43 citation statements)

References 33 publications

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“…Setting up NIRS is simple and the interpretation of the data does not require special training. In addition, findings of NIRS correlates well with information obtained with transcranial Doppler ultrasound (12). Thus, it is a preferred neurophysiological measuring method during aortic arch repair along with electroencephalogram today.…”

Section: Cerebral Monitoring During Rcpsupporting

confidence: 56%

“…Our group used transcranial power M-mode Doppler ultrasound during RCP to confirm the presence of reversed blood flow in the middle cerebral arteries, and we learned that "opening" pressure of 25 to 32 mmHg with RCP flow up to 1,500 mL/min for a very short period time was required to detect the reversal flow. After the blood flow in the middle cerebral arteries were observed, the RCP flow was then decreased to the maintenance flow rate below 500 mL/min with the superior vena cava line pressure below 25 mmHg and maintain the cerebral perfusion (12). We also found that snaring of the superior vena cava to isolate and clamping of the inferior vena cava cannula played an important role to control of superior vena cava pressure during RCP.…”

Section: Recommended Rcp Pressure and Flowmentioning

confidence: 68%

“…We have demonstrated in the past that the use of transcranial power M-mode Doppler ultrasound monitoring guided RCP improved neurological outcomes by individualized settings of pump flow (12). However, just like any ultrasound evaluations, transcranial Doppler monitoring is highly operator dependent; a stable fixation of the Doppler probe for continuous monitoring is cumbersome; and some patients do not have appropriate bone windows for transcranial monitoring.…”

Section: Cerebral Monitoring During Rcpmentioning

confidence: 99%

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Simple retrograde cerebral perfusion is as good as complex antegrade cerebral perfusion for hemiarch replacement

Tanaka

Estrera

2018

J. Vis. Surg.

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Cerebral complication is a major concern after aortic arch surgery, which may lead to death.Thus, cerebral protection strategy plays the key role to obtain respectable results in aortic arch repair.Deep hypothermic circulatory arrest was introduced in 1970s to decrease the ischemic insults to the brain.However, safe duration of circulatory arrest time was limited to 30 minutes. The 1990s was the decade of evolution for cerebral protection, in which two adjuncts for deep hypothermic circulatory arrest were introduced: retrograde and antegrade cerebral perfusion (ACP) techniques. These two cerebral perfusion techniques significantly decreased incidence of postoperative neurological dysfunction and mortality after aortic arch surgery. Although there are no large prospective studies that demonstrate which perfusion technique provide better outcomes, multiple retrospective studies implicate that ACP may decrease cerebral complications compared to retrograde cerebral perfusion (RCP) when a long circulatory arrest time is required during aortic arch reconstructions. To date, many surgeons favor ACP over RCP during a complex aortic arch repair, such as total arch replacement and hybrid arch replacement. However, the question is whether the use of ACP is necessary during a short, limited circulatory arrest time, such as hemiarch replacement? There is a paucity of data that proves the advantages of a complex ACP over a simple RCP for a short circulatory arrest time. RCP with deep hypothermic circulatory arrest is the simple, efficient cerebral protection technique with minimal interference to the surgical field-and it potentially allows to flush atheromatous debris out from the arch vessels. Thus, it is the preferred adjunct to deep hypothermic circulatory arrest during hemiarch replacement in our institution. arch surgery to obtain respectable outcomes. History of retrograde cerebral perfusion (RCP)Profound hypothermic circulatory arrest was introduced to aortic arch surgery in 1970s by Dr. Griepp and colleagues (3). Hypothermia minimizes the ischemic insults to the brain by suppressing its metabolic demand of glucose and oxygen. Circulatory arrest provided simplicity to the aortic arch surgery. However, safe duration of this technique soon became a concern. temporary neurologic dysfunction (TND) was often observed in patients with more than 25 minutes of profound hypothermic circulatory arrest, and its incidence was correlated with the duration of circulatory arrest by an odds ratio of 1.06 per minute (4). Svensson and colleagues reviewed outcomes of 656 patients and reported that the occurrence of PND significantly increased after 40 minutes of circulatory arrest time and the mortality rate significantly increased after 65 minutes of circulatory arrest (5). Thus, safe duration of profound hypothermic circulatory arrest time was recommended to limit up to 30 minutes.To augment the cerebral protection during the profound hypothermic circulatory arrest, in 1990 Ueda and colleagues introduced continuous RCP techn...

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Section: Cerebral Monitoring During Rcpsupporting

confidence: 56%

Section: Recommended Rcp Pressure and Flowmentioning

confidence: 68%

Section: Cerebral Monitoring During Rcpmentioning

confidence: 99%

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Simple retrograde cerebral perfusion is as good as complex antegrade cerebral perfusion for hemiarch replacement

Tanaka

Estrera

2018

J. Vis. Surg.

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“…The initial analysis of the International Registry of Acute Aortic Dissection (IRAD) reported a 26% operative mortality rate for patients with ATAAD [1]. Since that report, there have been a number of series from high-volume aortic centers demonstrating significantly lower mortality rates ranging from 9% to 15% [2][3][4][5]. Standard principles, including resection of the primary intimal tear and the use of hypothermic circulatory arrest (HCA) for the construction of an open distal anastomosis, have led to these improved results and are uniformly practiced at all high-volume aortic centers.…”

mentioning

confidence: 99%

Moderate Versus Deep Hypothermia With Unilateral Selective Antegrade Cerebral Perfusion for Acute Type A Dissection

Leshnower

Thourani

Halkos

et al. 2015

The Annals of Thoracic Surgery

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“…RCP allows a deep and homogeneous cooling of the brain as well as washing solid particles, air bubbles and metabolites, thereby decreasing acidosis in the ischemic brain (36). Associated with DH has allowed to reduce mortality, stroke (40,41) and delirium significantly with respect to the use of isolated DH (42)(43)(44).…”

Section: Rcpmentioning

confidence: 99%

Intraoperative care for aortic surgery using circulatory arrest

et al. 2017

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Abstract:The total circulatory arrest (CA) is necessary to achieve optimal surgical conditions in certain aortic pathologies, especially in those affecting the ascending aorta and aortic arch. During this procedure it is necessary to protect all the organs of ischemia, especially those of the central nervous system and for this purpose several strategies have been developed. The first and most important protective method is systemic hypothermia. The degree of hypothermia and the route of application have been evolving and currently tend to use moderate hypothermia (MH) (20.1-28 ℃) associated with unilateral or bilateral selective cerebral perfusion methods. In this way the neurological results are better, the interval of security is greater and the times of extracorporeal circulation are smaller. Even so, it is necessary to take into account that there is the possibility of ischemia in the lower part of the body, especially of the abdominal viscera and the spinal cord, therefore the time of circulatory stop should be limited and not to exceed 80 minutes. Evidence of possible neurological drug protection is very weak and only mannitol, magnesium, and statins can produce some benefit. Inhalational anesthetics and some intravenous seem to have advantages, but more studies would be needed to test their long-term benefit. Other important parameters to be monitored during these procedures are blood glucose, anemia and coagulation disorders and acid-base balance. The recommended monitoring is common in complex cardiovascular procedures and it is of special importance the neurological monitoring that can be performed with several techniques, although currently the most used are Bispectral Index (BIS) and Near-Infrared Spectroscopy (NIRS). It is also essential to monitor the temperature routinely at the nasopharyngeal and bladder level and it is important to control coagulation with rotational thromboelastometry (ROTEM).

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Ascending and Transverse Aortic Arch Repair

Cited by 85 publications

References 33 publications

Simple retrograde cerebral perfusion is as good as complex antegrade cerebral perfusion for hemiarch replacement

Simple retrograde cerebral perfusion is as good as complex antegrade cerebral perfusion for hemiarch replacement

Moderate Versus Deep Hypothermia With Unilateral Selective Antegrade Cerebral Perfusion for Acute Type A Dissection

Intraoperative care for aortic surgery using circulatory arrest

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