Retrograde and Antegrade Cerebral Perfusion: Results in Short Elective Arch Reconstructive Times

Milewski, Rita K.; Pacini, Davide; Moser, G.; Moeller, Patrick; Cowie, Doreen; Szeto, Wilson Y.; Woo, Y. Joseph; Desai, Nimesh D.; Marco, Luca Di; Pochettino, Alberto; Bartolomeo, Roberto Di; Bavaria, Joseph E.

doi:10.1016/j.athoracsur.2010.01.056

Cited by 92 publications

(90 citation statements)

References 27 publications

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“…This result is in contrast with the hypothesis that stroke is mainly due to embolism, but meanwhile it strengthens the idea that stroke is a combination of embolism and brain hypoperfusion [18,19]. On the other hand, TND was only influenced by DHCA duration, consistent with the finding that DHCA duration > 30 min was a significant predictor for TND [6,8,20].…”

Section: Discussioncontrasting

confidence: 57%

Cold reperfusion before rewarming reduces neurological events after deep hypothermic circulatory arrest

Mauro

Iacò

Lorenzo

et al. 2012

European Journal of Cardio-Thoracic Surgery

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OBJECTIVES: To identify a safety threshold of deep hypothermic circulatory arrest (DHCA) duration; to determine which protection offers the best outcome and whether a 10-min period of cold perfusion (20°C) preceding rewarming can reduce neurological events (NE). METHODS:From January 1988 to April 2009, 456 patients underwent aortic surgery using DHCA: for chronic disease in 239 and acute in 217. Cerebral protection was obtained by straight DHCA (sDHCA) in 69 cases, retrograde perfusion (RCP) in 198 and antegrade perfusion (ACP) in 189. In 247 subjects, a 10-min period of cold perfusion (20°C) preceded rewarming; in 209 rewarming was restarted without this preliminary. RESULTS:Fifty-eight patients (13%) experienced NE. Twenty-two (5%) suffered temporary neurological dysfunction (TND) and 36 (8%) suffered stroke. DHCA duration >30 min was predictive for higher rate of NE (25.2% vs. 2.0%, P 0.001); after this value, only ACP was able to reduce incidence of NE (16.5% vs. 30.5%, P = 0.035). Cold reperfusion before rewarming significantly reduced incidence of NE (7.7% vs. 18.7%, P < 0.001) and extended the safe period to 40 min. Thirty-day mortality was 16.0%. Predictors of higher early mortality were acute aortic disease, longer DHCA, lack of ACP or prompt rewarming when DHCA >30 min and postoperative stroke.CONCLUSIONS: sDHCA remains a safe and easy tool for cerebral protection when DHCA duration is expected to be less than 30 min. When aortic surgery requires a longer period, ACP should be instituted. Before rewarming, a 10-min period of cold perfusion significantly reduces incidence of NE.

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Section: Discussioncontrasting

confidence: 57%

Cold reperfusion before rewarming reduces neurological events after deep hypothermic circulatory arrest

Mauro

Iacò

Lorenzo

et al. 2012

European Journal of Cardio-Thoracic Surgery

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“…All 3 studies concluded that incidence of TND/PND and mortality was similar between the 2 cerebral protection adjuncts (TND, RCP 0-38% vs. ACP 1-34%; PND, RCP 1-9% vs. ACP 3-12%; mortality, RCP 3-6% vs. 2-4%). Retrospective studies composed of combined hemiarch and total arch replacement or limited to total arch replacement demonstrated similar results, with no significant difference between RCP and ACP regarding rates of mortality, TND, or PND as shown in the Table 1 (19,(23)(24)(25)(26)(27)(28). Of note, circulatory arrest time in recent reports is relatively short compared to decades ago, and this may have biased the difference between the 2 cerebral protection adjuncts.…”

Section: Comparison To Acpsupporting

confidence: 51%

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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“…Patients at our institution typically undergo arch reconstruction using either deep hypothermic arrest and retrograde cerebral perfusion (DHCA/RCP) or moderate hypothermic arrest and antegrade cerebral perfusion (MHCA/ACP). We have previously reported equivalent neurologic and mortality outcomes between these 2 techniques in patients undergoing elective aortic hemiarch procedures [2]. However, the degree of hypothermia required to achieve optimal distal organ protection is unknown, particularly regarding acute kidney injury (AKI), which remains associated with increased mortality in aortic arch operations [9,10].…”

mentioning

confidence: 99%

“…Many centers incorporate adjunctive cerebral perfusion techniques in an effort to improve neurologic outcomes [2][3][4][5][6][7][8]. Patients at our institution typically undergo arch reconstruction using either deep hypothermic arrest and retrograde cerebral perfusion (DHCA/RCP) or moderate hypothermic arrest and antegrade cerebral perfusion (MHCA/ACP).…”

mentioning

confidence: 99%

The Impact of Deep Versus Moderate Hypothermia on Postoperative Kidney Function After Elective Aortic Hemiarch Repair

Arnaoutakis

Vallabhajosyula

Bavaria

et al. 2016

The Annals of Thoracic Surgery

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We applied the sensitive RIFLE criteria to examine AKI in patients undergoing elective aortic hemiarch replacement for aneurysmal disease. Baseline renal dysfunction, lower ejection fraction, and longer CPB time are independent predictors of AKI. Compared with DHCA/RCP, our data suggest that an MHCA/ACP cerebral protection strategy does not appear to be associated with worse postoperative renal outcomes.

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Retrograde and Antegrade Cerebral Perfusion: Results in Short Elective Arch Reconstructive Times

Cited by 92 publications

References 27 publications

Cold reperfusion before rewarming reduces neurological events after deep hypothermic circulatory arrest

Cold reperfusion before rewarming reduces neurological events after deep hypothermic circulatory arrest

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

The Impact of Deep Versus Moderate Hypothermia on Postoperative Kidney Function After Elective Aortic Hemiarch Repair

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