Intermittent antegrade/selective cerebral perfusion during circulatory arrest for repair of the aortic arch

Abstract

If the aortic arch requires repair or replacement due to an aneurysm or dissection, conventional cardiopulmonary bypass (CPB) is not possible during the period in which the aortic arch is excluded from the circulation. This creates a situation in which there is no cerebral circulation. The brain needs adequate protection from this ischaemic insult.

Hypothermic circulatory arrest (HCA), antegrade/selective cerebral perfusion (ASCP) and retrograde cerebral perfusion (RCP) are reported to exhibit their cerebral protective capabilities during procedures involving the aortic arch. HCA can provide adequate protection in procedures of short duration and avoids the complications associated with cerebral perfusion techniques. The main disadvantage of HCA is that the ‘safe’ duration of circulatory arrest is not clearly defined. Topical cooling of the head may enhance cerebral hypothermia and provide additional protection. If longer periods of circulatory arrest are anticipated or occur unexpectedly, we suggest that ASCP can offer improved cerebral protection by providing adequate brain perfusion and improved cerebral cooling. By using a coronary sinus perfusion catheter as a carotid artery cannula, it is not necessary to snare or clamp the carotid arteries. This technique minimizes the chance of damaging the carotid arteries. In this report, we describe our set-up and ASCP perfusion protocol for the surgical repair of an aortic arch aneurysm.

Get full access to this article

View all access options for this article.

References

Crittenden MD , Roberts CS , Rosa L et al. Brain protection during circulatory arrest . Ann Thorac Surg 1991; 51: 942-947 .

Midulla PS , Gandsas A , Sadeghi AM et al. Comparison of retrograde cerebral perfusion to antegrade cerebral perfusion and hypothermic circulatory arrest in a chronic porcine model . J Card Surg 1994; 9: 560-575 .

Ergin MA , Griepp EB , Lansman SL et al. Hypothermic circulatory arrest and other methods of cerebral protection during operations on the thoracic aorta . J Card Surg 1994; 9: 525-537 .

Fukae K , Nakashima A , Hisahara M et al. Maldistribution of the cerebral bloodflow in retrograde cerebral perfusion . J Card Surg 1995; 9: 496-501 .

Chanyi S et al. Cerebral perfusion and hypothermic circulatory arrest . J Cardiothorac Vasc Anesthesia 1996; 10: 75-82 .

Swain JA , Anderson RV , Siegman MG. Low-flow cardiopulmonary bypass and cerebral protection: a summary of investigations . Ann Thorac Surg 1993; 56: 1490-1492 .

O’Dwyer C , Prough DS , Johnston WE. Determinants of cerebral perfusion during cardiopulmonary bypass . J Cardiothorac Vasc Anesthesia 1996; 10: 54-65 .

Boeckxstaens CJ , Flameng WJ. Retrograde cerebral perfusion does not perfuse the brain tissue: a study in primates using colored microspheres . Course syllabus: Pathophysiology and techniques of cardiopulmonary bypass, 1996.

Boeckxstaens CJ , Flameng WJ. The effect of deep hypothermia on regional bloodflow: an experimental study using colored microsphere technique . Course syllabus: Pathophysiology and techniques of cardiopulmonary bypass, 1996.

10.

Stone JB , Young WL , Smith CR , Solomon RA.

Do standard monitoring sites reflect true brain temperature when profound hypothermia is rapidly induced and reversed?

Anesthesiology 1995; 82: 311-351 .

11.

Kirklin JW , Barratt-Boyes BG. Hypothermia circulatory arrest and cardiopulmonary bypass. In: Cardiac surgery, 2nd edn. New York: Churchill Livingstone , 1993: 61-127.

12.

Hickey PR , Andersen NP. Deep hypothermic circulatory arrest: a review of pathophysiology and clinical experience as a basis for anesthetic management . J Cardiothorac Anesth 1987; 1: 137-155 .