Vol. 20 No. 4 (2016)
ORIGINAL ARTICLES: AORTIC ARCH SURGERY

Cerebral and visceral organ protection during aortic arch surgery. Intraoperative tactics and monitoring details

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  • Yu. Belov,
  • E. Charchyan,
  • B. Akselyrod,
  • D. Gusykov,
  • S. Fedulova,
  • A. Eremenko,
  • A. Skvorcov ,
  • Z. Hachatryan,
  • L. Medvedeva,
  • A. Oystrah
Yu. Belov
Petrovsky Russian Research Centre of Surgery, Ministry of Health Care of Russian Federation, 119991, Moscow, Russian Federation
E. Charchyan
Petrovsky Russian Research Centre of Surgery, Ministry of Health Care of Russian Federation, 119991, Moscow, Russian Federation
B. Akselyrod
Petrovsky Russian Research Centre of Surgery, Ministry of Health Care of Russian Federation, 119991, Moscow, Russian Federation
D. Gusykov
Petrovsky Russian Research Centre of Surgery, Ministry of Health Care of Russian Federation, 119991, Moscow, Russian Federation
S. Fedulova
Petrovsky Russian Research Centre of Surgery, Ministry of Health Care of Russian Federation, 119991, Moscow, Russian Federation
A. Eremenko
Petrovsky Russian Research Centre of Surgery, Ministry of Health Care of Russian Federation, 119991, Moscow, Russian Federation
A. Skvorcov 
Petrovsky Russian Research Centre of Surgery, Ministry of Health Care of Russian Federation, 119991, Moscow, Russian Federation
Z. Hachatryan
Petrovsky Russian Research Centre of Surgery, Ministry of Health Care of Russian Federation, 119991, Moscow, Russian Federation
Bio
L. Medvedeva
Petrovsky Russian Research Centre of Surgery, Ministry of Health Care of Russian Federation, 119991, Moscow, Russian Federation
A. Oystrah
Petrovsky Russian Research Centre of Surgery, Ministry of Health Care of Russian Federation, 119991, Moscow, Russian Federation
DOI: https://doi.org/10.21688/1681-3472-2016-4-34-44

Published 2016-12-30

Keywords

  • aortic arch replacement,
  • antegrade cerebral perfusion,
  • circulatory arrest,
  • hypothermia

How to Cite

Belov, Y., Charchyan, E., Akselyrod, B., Gusykov, D., Fedulova, S., Eremenko, A., Skvorcov , A., Hachatryan, Z., Medvedeva, L., & Oystrah, A. (2016). Cerebral and visceral organ protection during aortic arch surgery. Intraoperative tactics and monitoring details. Patologiya Krovoobrashcheniya I Kardiokhirurgiya, 20(4), 34–44. https://doi.org/10.21688/1681-3472-2016-4-34-44

Copyright (c) 2016 Belov Yu.V., Charchyan E.R., Akselyrod B.A., Gusykov D.A., Fedulova S.V., Eremenko A.A., Skvorcov A.A., Hachatryan Z.R., Medvedeva L.A., Oystrah A.S.

Creative Commons License

This work is licensed under a Creative Commons Attribution 4.0 International License.

Abstract

Aim. The study is aimed at presenting the protocol of intraoperative organ protection, analyzing its effectiveness during aortic arch surgery and evaluating the rate of postoperative complications in this group of patients.
Methods. The study included 141 patients. In the first group (n=70) patients underwent aortic arch surgery with hypothermic circulatory arrest (target core temperature 26 °C) and antegrade cerebral perfusion. Patients of the second group (n=71) underwent ascending aortic replacement using cardiopulmonary bypass with moderate hypothermia (target core temperature 32 °C). Cerebral and tissue oxygenation monitoring was performed in all the cases. In the first group transcranial Doppler monitoring was also performed. 33 patients in the first group and 34 patients in the second group underwent testing before and after surgery in order to evaluate cognitive function. Patients’ condition was evaluated during the in-hospital period that was about 15.97±20.54 days.
Results. In-hospital mortality rate was 4,2 % in the first group and 0% in the second one (p=0.12). Stroke was observed in 1.4 and 0 % of cases respectively. The rate of encephalopathy (as the leading symptom) was 7.1 and 5.6 % in 1st and 2nd groups respectively. Multimodal monitoring enabled to dynamically adjust the flow rate of antegrade cerebral perfusion. As a result, cerebral SctO2 and linear velocity were maintained within the acceptable range.
Conclusion. The presented protocol proved to be effective, it allows to perform aortic arch surgery with the same postoperative neurological complications’ rate as after ascending aortic replacement. We recommend performing reconstructive aortic arch surgery by using moderate hypothermic circulatory arrest (26-28 °С) and selective antegrade cerebral perfusion. In this modality, it is important to perform the distal anastomosis quickly and start patient’s rewarming (this will significantly shorten the duration of cardiopulmonary bypass and, as a result, decrease the rate of postoperative complications) and to carry out both precise intraoperative monitoring of the brain condition (by using cerebral oxymetry and transcranial Doppler) and central core temperature.

Received 21 June 2016. Accepted 21 October 2016.

Funding: The study had no sponsorship.
Conflict of interest: The authors declare no conflict of interest.
Author contributions
Conceptualization and study design: Belov Yu.V., Charchyan E.R., Akselrod B.A.
Material acquisition and analysis: Khachatryan Z.R., Oystrakh A.S., Medvedeva L.A., Guskov D.A., Fedulova S.V.
Statistical data processing: Khachatryan Z.R., Guskov D.A., Skvortsov A.A.
Article writing: Akselrod B.A., Khachatryan Z.R., Skvortsov A.A.
Review & editing: Charchyan E.R., Akselrod B.A., Eremenko A.A., Belov Yu.V.

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References

  1. Griepp RB, Stinson EB, Hollingsworth JF, Buehler D. Prosthetic replacement of the aortic arch. J Thorac Cardiovasc Surg. 1975;70(6):1051-63.
  2. Borst HG, Schaudig A, Rudolph W. Arteriovenous fistula of the aortic arch: repair during deep hypothermia and circulatory arrest. J Thorac Cardiovasc Surg. 1964;48:443-7.
  3. Urbanski PP, Luehr M, Di Bartolomeo R, Diegeler A, De Paulis R, Esposito G, Bonser RS, Etz CD, Kallenbach K, Rylski B, Shrestha ML, Tsagakis K, Zacher M, Zierer A. Multicentre analysis of current strategies and outcomes in open aortic arch surgery: heterogeneity is still an issue. Eur J Cardiothorac Surg. 2016;50(2):249-55. http://dx.doi.org/10.1093/ejcts/ezw055
  4. ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease: Executive Summary. Circulation. 2010;121(13):1544-79. https://doi.org/10.1161/CIR.0b013e3181d47d48
  5. Griepp RB, Bonser R, Haverich A, Kazui T, Kouchoukos NT, Safi HJ, Sasaki H, Spielvogel D, Takamoto S. Panel Discussion: Session П-Aortic Arch. Ann Thorac Surg. 2007;83(2):S824-31. http://dx.doi.org/10.1016/j.athoracsur.2006.11.093
  6. Coselli JS, LeMaire SA. Experience with RCP during proximal aortic surgery in 290 patients. J Card Surg. 1997;12(2 Suppl):322-5.
  7. Bachet J, Guilmet D, Goudot B, Dreyfus GD, Delentdecker P, Brodaty D, Dubois C. Antegrade cerebral perfusion with cold blood: a 13-year experience. Ann Thorac Surg. 1999;67(6):1874-8.
  8. De Paulis R, Czerny M, Weltert L, Bavaria J, Borger MA, Carrel TP, Etz CD, Grimm M, Loubani M, Pacini D, Resch T, Urbanski PP, Weigang E; EACTS Vascular Domain Group. Current trends in cannulation and neuroprotection during surgery of the aortic arch in Europe. Eur J Cardiothorac Surg. 2015;47(5):917-23. http://dx.doi.org/10.1093/ejcts/ezu284
  9. Luehr M, Bachet J, Mohr FW, Etz CD. Modern temperature management in aortic arch surgery; the dilemma of moderate hypothermia. Eur J Cardiothorac Surg. 2014:45(1):27-39. http://dx.doi.org/10.1093/ejcts/ezt154
  10. Ehrlich MP, McCullough JN, Zhang N, Weisz DJ, Juvonen T, Bodian CA, Griepp RB. Effect of hypothermia on cerebral blood flow and metabolism in the pig. Ann Thorac Surg. 2002;73(1):191-7.
  11. Haverich A, Hagl C. Organ protection during hypothermic circulatory arrest. J Thorac Cardiovasc Surg. 2003;125(3):460-2. http://dx.doi.org/10.1067/mtc.2003.291
  12. Reich DL, Uysal S, Sliwinski M, Ergin MA, Kahn RA, Konstadt SN, McCullough J, Hibbard MR, Gordon WA, Griepp RB. Neuropsychologic outcome after deep hypothermic circulatory arrest in adults. J Thorac Cardiovasc Surg. 1999;117(1):156-63.
  13. McCullough JN, Zhang N, Reich DL, Juvonen TS, Klein JJ, Spielvogel D, Ergin MA, Griepp RB. Cerebral metabolic suppression during hypothermic circulatory arrest in humans. Ann Thorac Surg. 1999;67(6):1895-9.
  14. Cooley DA, De Bakey ME. Resection of entire ascending aorta in fusiform aneurysm using cardiac bypass. J Am Med Assoc. 1956;162(12):1158-9.
  15. Guilmet D, Roux PM, Bachet J, Goudot B, Tawil N, Diaz F. A new technique of cerebral protection. Surgery of the aortic arch. Presse Med. 1986;15(23):1096-8.
  16. Kazui T. Update in surgical management of aneurysms of the thoracic aorta. Rinsho Kyobu Geka. 1986;6(1):7-15.
  17. Urbanski PP, Lenos A, Blume JC, Ziegler V, Griewing B, Schmitt R, Diegeler A, Dinkel M. Does anatomical completeness of the circle of Willis correlate with sufficient cross-perfusion during unilateral cerebral perfusion? Eur J Cardiothorac Surg. 2008;33(3):402-8. http://dx.doi.org/10.1016/j.ejcts.2007.12.021
  18. Urbanski PP, Lenos A, Bougioukakis P, Neophytou I, Zacher M, Diegeler A. Mild-to-moderate hypothermia in aortic arch surgery using circulatory arrest: a change of paradigm? Eur J Cardiothorac Surg. 2012;41(1):185-91. http://dx.doi.org/10.1016/j.ejcts.2011.03.060
  19. Leshnower BG, Myung RJ, Kilgo PD, Vassiliades TA, Vega JD, Thourani VH, Puskas JD, Guyton RA, Chen EP. Moderate hypothermia and unilateral selective antegrade cerebral perfusion: a contemporary cerebral protection strategy for aortic arch surgery. Ann Thorac Surg. 2010;90(2):547-54. http://dx.doi.org/10.1016/j.athoracsur.2010.03.118
  20. Krahenbühl ES, Clement M, Reineke D, Czerny M, Stalder M, Aymard T, Schmidli J, Carrel T. Antegrade cerebral protection in thoracic aortic surgery: lessons from the past decade. Eur J Cardiothorac Surg. 2010;38(1):46-51. http://dx.doi.org/10.1016/j.ejcts.2010.01.016
  21. Haldenwang PL, Strauch JT, Amann I, Klein T, Sterner-Kock A, Christ H, Wahlers T. Impact of pump flow rate during selective cerebral perfusion on cerebral hemodynamics and metabolism. Ann Thorac Surg. 2010;90(6):1975-84. http://dx.doi.org/10.1016/j.athoracsur.2010.06.111
  22. Misfeld M, Leontyev S, Borger MA, Gindensperger O, Lehmann S, Legare JF, Mohr FW. What is the best strategy for brain protection in patients undergoing aortic arch surgery? A single center experience of 636 patients. Ann Thorac Surg. 2012;93(5):1502-8. http://dx.doi.org/10.1016/j.athoracsur.2012.01.106
  23. Gregory A, Kohl BA. Con: Near-Infrared Spectroscopy has not Proven its Clinical Utility as a Standard Monitor in Cardiac Surgery. J Cardiothorac Vasc Anesthesia. 2013;27(2):390-94. http://dx.doi.org/10.1053/j.jvca.2012.11.010
  24. Hashimi S, Zaman M., Waterworth P., Bilal H. Does the use of thiopental provide added cerebral protection during deep hypothermic circulatory arrest? Interact Cardiovasc Thorac Surg. 2013;17(2):392-7. http://dx.doi.org/10.1093/icvts/ivt184
  25. Sessler D. Temperature monitoring and perioperative thermoregulation. Anesthesiology. 2008;109(2):318-38. http://dx.doi.org/10.1097/ALN.0b013e31817f6d76