Asian Cardiovasc Thorac Ann 1999;7:27-29
© 1999 Asia Publishing EXchange Pte Ltd
Retrograde Cerebral Perfusion for Aortic Arch Surgery in Octogenarians
Hitoshi Ogino, MD,
Yuichi Ueda, MD,
Takaaki Sugita, MD,
Yutaka Sakakibara, MD,
Katsuhiko Matsuyama, MD,
Keiji Matsubayashi, MD,
Takuya Nomoto, MD
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Department of Cardiovascular Surgery Tenri Hospital Nara, Japan
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For reprint information contact: Hitoshi Ogino, MD Tel: 81 743 63 5611 Fax: 81 743 62 5576 Department of Cardiovascular Surgery, Tenri Hospital, 200 Mishima-cho, Tenri, Nara 632-8552, Japan.
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Abstract
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We reviewed our surgical management of aortic arch aneurysms in 11 octogenarians. Seven operations (63.6%) were performed on an emergency basis for ruptured atherosclerotic aneurysm in 5 cases and for acute dissection in 2. Deep-hypothermic circulatory arrest, continuous retrograde cerebral perfusion, and open aortic anastomosis were employed routinely for brain protection during aortic arch replacement. There was one intraoperative death due to hemorrhage. One survivor died of bowel necrosis 47 days postoperatively and another suffered sudden death 5 months postoperatively. Both of these patients had been treated for a ruptured aneurysm and had suffered from postoperative neurological deficit. There were 2 late deaths due to unrelated events: subarachnoid hemorrhage and hepatic failure. The surgical outcomes were considered satisfactory, except in emergency cases of ruptured aneurysm where there was a high mortality and neurological morbidity. It is recommended that arch aneurysms at risk of rupture should be repaired electively before rupture, even in octogenarians, using deep-hypothermic circulatory arrest, continuous retrograde cerebral perfusion, and open aortic anastomosis.
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Introduction
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Although there are many reports concerning cardiac operations, few have focused on the formidable problem of thoracic aortic surgery in the elderly, particularly for aortic arch aneurysm.1,2 We describe our experience of the surgical challenges of treating aortic arch aneurysms in octogenarians, using deep-hypothermic circulatory arrest, continuous retrograde cerebral perfusion, and open aortic anastomosis.3–5
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Patients and Methods
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Eleven patients over 80 years old underwent replacement of the aortic arch (Table 1
). Seven operations (63.6%) were performed on an emergency basis, of which 5 were for a ruptured atherosclerotic aneurysm and 2 were for acute Stanford type A aortic dissection. The sites involved in atherosclerotic aneurysms are shown in Table 1. The other 2 patients had acute Stanford type A aortic dissection of the ascending aorta to the proximal aortic arch. We employed a median sternotomy, deep-hypothermic circulatory arrest, continuous retrograde cerebral perfusion, and open aortic anastomosis for brain protection, as described elsewhere.3–6 Standard cardiopulmonary bypass was established via bicaval venous drainage and aortic or femoral arterial return. The superior vena cava was snared. After the patient was cooled to a nasopharyngeal temperature of 18°C, circulatory arrest was initiated with pressure in the superior vena cava of 15 mm Hg. During circulatory arrest, the brain was perfused retrogradely via a superior vena cava cannula with pressure in the superior vena cava of 15 mm Hg.4,6 To prevent embolism and aortic damage, no aortic clamping was applied on any site around the aortic arch.5,6 Hemashield grafts (Meadox Medicals, Inc., Oakland, NY, USA) size 24 or 26 mm were used. Seven patients underwent total arch replacement, mostly with individual reconstruction of the arch vessels (Table 1).
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Results
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The mean duration of circulatory arrest, retrograde cerebral perfusion, cardiopulmonary bypass, and operation are shown in Table 2. In one emergency case of a huge ruptured aneurysm, the patient died intraoperatively of uncontrollable hemorrhage from the distal anastomosis site (Table 3). In another emergency case of ruptured aneurysm, the patient had a stroke after total arch replacement and died of bowel necrosis due to thrombosis of the superior mesenteric artery on postoperative day 47. In the late stage, one patient who had been treated for a ruptured aneurysm died 5 months postoperatively, having never regained total consciousness because of cerebral malperfusion caused by severe stenosis of the left carotid artery associated with preoperative shock. Another 2 patients died of unrelated events: subarachnoid hemorrhage; and hepatic failure after incidental thrombosis of the superior mesenteric artery during hospitalization. The operative mortality rate was 9% and the late mortality rate including an in-hospital death was 40%. Of the 10 patients who survived the operation, neurological deficit occurred in 2 (20%); one fell into vegetative status and another had a stroke, both eventually died as described above.
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Discussion
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Our results of aortic arch operations with a high incidence of emergency surgery in conjunction with deep-hypothermic circulatory arrest, continuous retrograde cerebral perfusion, and open aortic anastomosis were fairly favorable in these 11 octogenarians. There are many challenging aspects of such surgery: (1) protection of the brain, spine, myocardium, and other vital organs; (2) techniques for preventing atheromatous embolism and aortic damage; (3) how to reconstruct the arch vessels; (4) avoidance of coagulopathy. The elderly tend to have more marked atherosclerosis of extensive areas of the aorta, resulting in cerebral or systemic embolism and vital organ malperfusion.7 Therefore, aortic arch surgery for the elderly is associated with a high mortality rate and poor recovery. In particular, prevention of neurological complications is vital since the elderly generally have unfavorable intracranial or carotid arterial lesions as well as severe arch pathologies.
Three of the patients who died postoperatively had a serious ruptured aneurysm that prevented close examination of their aortic lesions and coexisting disorders and consequent preparation. Furthermore, patients with a ruptured aneurysm are normally in a critical condition with hypotension or profound shock, organ dysfunction, loss of consciousness, and severe blood loss. These adverse circumstances generally lead to unfavorable outcomes although 4 emergency patients including 2 with aortic dissection did survive. In contrast, all 4 electively treated patients survived although 2 of them died eventually from unrelated events. Thus, the mortality rate was considered to be satisfactory except for emergency cases of ruptured aneurysm given the age of the patients and the high risk of such surgery with its challenging features.
Two patients developed neurological deficit after circulatory arrest of 55 and 68 minutes. Both were emergency cases of ruptured aneurysm with hypotension before surgery. One had stenosis of the left carotid artery with cerebral hypoperfusion. However, in terms of duration of circulatory arrest, prolonged arrest in conjunction with continuous retrograde cerebral perfusion proved to be safe in 3 survivors without any dysfunction; their durations of cardiac arrest were 91, 67, and 74 minutes.8,9 The benefits of retrograde cerebral perfusion include oxygenation, cooling, supply of substances, and back-flushing of adverse metabolites. In addition, evacuation of particulate debris and air from the aortic arch is expected.4,6 The elderly usually have more severe or more complex atherosclerotic lesions in the arch and arch vessels that take longer to repair.7 Hypothermic circulatory arrest alone might have been insufficient for adequate brain protection because its cerebral safety is limited to 45 minutes at 20°C.8 The combination of circulatory arrest and continuous retrograde cerebral perfusion is considered to have a limit of cerebral safety of 80 to 90 minutes at 18°C.6 The alternative of selective antegrade cerebral perfusion that could prolong the cerebral safety limit carries a risk of cerebral embolism or cerebral malperfusion due to intracranial arterial stenosis in the elderly. Consequently, the combination of deep- hypothermic circulatory arrest continuous retrograde cerebral perfusion, and open aortic anastomosis was considered to be the best option for arch surgery in octogenarians.
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Conclusion
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We concluded that the surgical results of aortic arch aneurysm repair in octogenarians were satisfactory except in emergency cases of ruptured atherosclerotic aneurysms where there was high morality and neurological impairment.10 Arch aneurysms with a risk of rupture should therefore be repaired electively before rupture even in octogenarians, provided that the patients are suitable surgical candidates in good physical and mental condition. The combination of deep-hypothermic circulatory arrest, continuous retrograde cerebral perfusion, and open aortic anastomosis is recommended.
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References
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Abstract
Introduction
