External carotid compression: a novel technique to improve cerebral perfusion during selective antegrade cerebral perfusion for aortic arch surgery

Abstract

External carotid compression: a novel technique to improve cerebral perfusion during selective antegrade cerebral perfusion for aortic arch surgery La compression externe de la carotide: une technique innovante pour améliorer la perfusion cérébrale pendant une perfusion cérébrale antérograde sélective pour une chirurgie de la crosse aortique Abstract Purpose Selective antegrade cerebral perfusion (SACP) involving cannulation of either the axillary or innominate artery is a commonly used technique for maintaining cerebral blood flow (CBF) during the use ofhypothermic cardiac arrest (HCA) for operations on the aortic arch. Nevertheless, asymmetrical CBF with hypoperfusion of the left cerebral hemisphere is a common occurrence during SACP. The purpose of this report is to describe an adjunctive maneuver to improve left hemispheric CBF during SACP by applying extrinsic compression to the left carotid artery. Clinical features A 77-yr-old male patient with a history of aortic valve replacement presented for emergent surgical repair of an acute type A aortic dissection of a previously known ascending aortic aneurysm. His intraoperative course included cannulation of the right axillary artery, which was used as the aortic inflow during cardiopulmonary bypass and also allowed for subsequent SACP during HCA. After the onset of HCA, the innominate artery was clamped at its origin to allow for SACP. Shortly thereafter, however, the left-sided cerebral oxygen saturation (SrO 2 ) began to decrease. Augmenting the PaO 2 , PaCO 2 and both SACP pressure and flow failed to increase left hemispheric SrO 2 . Following the use of ultrasound guidance to confirm the absence of atherosclerotic disease in the carotid artery, external pressure was applied partially compressing the artery. With the carotid compression, the left cerebral saturation abruptly increased, suggesting pressurization of the left cerebral hemispheric circulation and augmentation of CBF. Conclusions Direct ultrasound visualization and cautious partial compression of the left carotid artery may address asymmetrical CBF that occurs with SACP during HCA for aortic arch surgery. This strategy may lead to improved symmetry of CBF and corresponding cerebral oximetry measurements during aortic arch surgery. RésuméObjectif La perfusion cérébrale antérograde sélective réalisée via la canulation de l'artère axillaire ou du tronc artériel brachiocéphalique est une technique répandue pour maintenir la circulation sanguine cérébrale pendant un arrêt circulatoire hypothermique pour les opérations de la crosse aortique. Toutefois, on observe fréquemment une circulation sanguine cérébrale asymétrique accompagnée d'une hypoperfusion de l'hémisphère cérébrale gauche pendant la perfusion cérébrale antérograde sélective. L'objectif de ce compte rendu est de décrire une manoeuvre d'appoint destinée à améliorer la circulation sanguine cérébrale pendant la Electronic supplementary material The online version of this article

Cannulation strategies in type A aortic dissection: a novel insight narrative review

“…When the numeric value of rSO 2 is lesser than 20% of the baseline value or an absolute value of 50, insufficient cerebral perfusion needs to be carefully identified (87); therefore, effective measures, such as the appropriate increase of CO 2 , maintaining blood flow and blood pressure, adjusting the position of cannulation or adding bilateral/global brain perfusion, need to be adopted to improve brain perfusion (88). Also, other assisting approaches, including using a balloon-tip cannula inserted into the left carotid artery (89), direct external clamping of the left carotid artery near its origin from the aortic arch, and application of external pressure with the ultrasound probe to partially compress the left carotid artery, will reduce the carotid "steal" phenomenon and increase rSO 2 (90) .…”