Continuous Retrograde Cerebral Perfusion Research Articles

Adjunct retrograde cerebral perfusion provides superior outcomes compared with hypothermic circulatory arrest alone: A meta-analysis

ObjectiveRetrograde cerebral perfusion is becoming less frequently used as a method of neuroprotection during aortic surgery. The present meta-analysis aims to compare outcomes after arch surgery with hypothermic circulatory arrest versus hypothermic circulatory arrest + retrograde cerebral perfusion. MethodsElectronic searches were performed using 7 databases from their inception to September 2016. Relevant comparative studies that included patient groups who underwent aortic arch surgery using hypothermic circulatory arrest with continuous retrograde cerebral perfusion or hypothermic circulatory arrest alone were identified, and data were extracted by 2 independent researchers. Data were aggregated using a random-effects model per predefined clinical end points. ResultsTwenty-eight comparative studies were identified, with 2705 hypothermic circulatory arrest cases and 2817 hypothermic circulatory arrest + retrograde cerebral perfusion cases. No significant differences were seen between both groups in terms of age, gender, proportion of dissections and aneurysms, and hemiarch/total arch repair. The hypothermic circulatory arrest + retrograde cerebral perfusion group had slightly longer cardiopulmonary bypass time and lower body arrest time. Mortality was significantly increased for the hypothermic circulatory arrest cohort compared with the hypothermic circulatory arrest + retrograde cerebral perfusion cohort (odds ratio, 1.75; 95% confidence interval, 1.16-2.63; P = .007; I2 = 54%), but not on pooling of adjusted estimates. Stroke was also increased for the hypothermic circulatory arrest cohort (odds ratio, 1.50; 95% confidence interval, 1.07-2.10; P = .02; I2 = 29%). No difference in temporary neurologic deficit was identified (P = .66). Meta-regression found the treatment effect for mortality and stroke to be less pronounced in more contemporary series. ConclusionsThese results suggest that the addition of retrograde cerebral perfusion during aortic arch surgery may provide better outcomes than using hypothermic circulatory arrest alone, although significant confounders exist. Further robust studies are required to confirm the utility of retrograde cerebral perfusion in arch surgery.

A reappraisal of retrograde cerebral perfusion.

Brain protection during aortic arch surgery by perfusing cold oxygenated blood into the superior vena cava was first reported by Lemole et al. In 1990 Ueda and associates first described the routine use of continuous retrograde cerebral perfusion (RCP) in thoracic aortic surgery for the purpose of cerebral protection during the interval of obligatory interruption of anterograde cerebral flow. The beneficial effects of RCP may be its ability to sustain brain hypothermia during hypothermic circulatory arrest (HCA) and removal of embolic material from the arterial circulation of the brain. RCP can offer effective brain protection during HCA for about 40 to 60 minutes. Animal experiments revealed that RCP provided inadequate cerebral perfusion and that neurological recovery was improved with selective antegrade cerebral perfusion (ACP), however, both RCP and ACP provide comparable clinical outcomes regarding both the mortality and stroke rates by risk-adjusted and case-matched comparative study. RCP still remains a valuable adjunct for brain protection during aortic arch repair in particular pathologies and patients.

Persistence of intra-aortic air after circulatory arrest

Circulatory arrest and open aortic anastomosis can result in air entering the arterial system.1Ueda Y. Miki S. Kusuhara K. Okita Y. Tahata T. Yamanaka K. Deep hypothermic systemic circulatory arrest and continuous retrograde cerebral perfusion for surgery of aortic arch aneurysm.Eur J Cardiothorac Surg. 1992; 6: 36-41Crossref PubMed Scopus (98) Google Scholar, 2Sung S.C. Jun H.J. Woo J.S. Simplified retrograde systemic perfusion for removal of air from the aorta in an infant.Ann Thorac Surg. 2001; 71: 362-364Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar However, the fate and location of such air is unknown. It is assumed that it embolizes in small peripheral arteries immediately on resumption of normal antegrade circulation. We undertook aortic valve replacement and hemiarch replacement on a 77-year-old man with aortic valve stenosis, a small abdominal aortic aneurysm of 30 mm (A), and acute aortic dissection. Cardiopulmonary bypass was established by femoral arterial and bicaval cannulations. Open distal aortic anastomosis was performed under hypothermic circulatory arrest. We placed the patient in the Trendelenburg head position and used carbon dioxide field flooding. Circulatory arrest time was 17 minutes. Mechanical de-airing of the aorta was done by retrograde femoral arterial perfusion before antegrade circulation was restarted. After transfer to the intensive care unit, the patient's right femoral pulse became unpalpable. A computed tomography (CT) scan was taken to identify the cause at 2 hours after the end of surgery, which corresponded to 6 hours after cessation of the circulatory arrest. An arterial lesion was found at the femoral cannulation site. However, the CT scan also revealed a pocket of intra-aortic air (B and C) at lumbar vertebral level 3-4 (Cover). It was determined that the air had become trapped during the circulatory arrest and had persisted for at least 6 hours, during which time the patient remained supine. There was no indication that the patient sustained an air embolism of any of the abdominal organs. During the femorofemoral bypass surgery for the leg ischemia, the aorta was briefly allowed to self-flush to purge the air through the femoral artery. In clinical situations, opportunities for detecting intra-aortic air after surgery requiring circulatory arrest are rare. Our finding suggests that air introduced during circulatory arrest can remain much longer than expected despite dynamic aortic blood flow and the changes in body position occurring through patient transfer. Download .jpg (.57 MB) Help with files Cover

Surgical pitfalls during explantation of a thoracic aortic endoprosthesis

The loss of cyclooxygenase in platelets, which lack the capacity for new protein synthesis, constitutes a loss of function for the remainder of their lifetime. The average life span of platelets is 7 days; therefore the conventional practice is to stop aspirin therapy 1 week before the planned procedure. However, the results of this study show that inhibition of platelet aggregation with aspirin vanishes earlier than expected. The life span of the platelet and platelet aggregation as a whole need to be understood separately. Although it may take 10 days for the total platelet population to be renewed and thus restore normal cyclooxygenase activity, it has been shown in vitro that if as few as 20% of total platelets have normal cyclooxygenase activity, aggregation would remain normal. Our study has confirmed this finding in the clinical situation. This study has several limitations. One of these is the small study population. We therefore should extend this study and investigate the outcomes. Another limitation concerns aspirin dosages, which were low (81 mg/d) in this study. If the aspirin dosage had been higher, the speed of recovery of aggregation might have been different. In conclusion, this study indicates that inhibition of platelet

Retrograde cerebral perfusion with hypothermic circulatory arrest in aortic arch surgery: operative and long-term results.

Clinical data were retrospectively collected for 207 consecutive patients who underwent aortic arch surgery using continuous retrograde cerebral perfusion (CRCP) and hypothermic circulatory arrest (HCA) at Tenri Hospital (138 patients) from 1988 to 1999, and at Nagoya University Hospital (69 patients) from 1990 to 2000. One hundred and 3 patients (50%) were operated upon for aortic dissection, and 104 patients (50%) for atherosclerotic aneurysm. Hospital mortality was 12% (25 patients). HCA times were 44+/-20 minutes. Cardiopulmonary bypass time longer than 6 hours, low cardiac output syndrome, respiratory failure, and central nervous system (CNS) dysfunction contributed to hospital deaths. Late mortality was 16% (34 patients). The predictors of late deaths were age (>70 years), total arch replacement, HCA time >60 min., non-dissecting aneurysm, and postoperative CNS injury. Operative results of aortic arch surgery using CRCP was generally satisfactory. However, the long-term results of total arch replacement for patients older than 70 years, non-dissecting aneurysm (particularly ruptured), and postoperative CNS injury were poor. Although prolonged duration of HCA may contribute to these poor results, other factors such as emergent surgery, late death due to aging, and systemic atherosclerosis are also considered to be risk factors.

Intermittent Retrograde Cerebral Perfusion During Prolonged Period of Hypothermic Circulatory Arrest: A Study in a Chronic Porcine Model

Previous studies have shown that although retrograde cerebral perfusion (RCP) improves cerebral outcome during hypothermic circulatory arrest (HCA), RCP exposes the brain to subsequent edema. In this study, we have compared intermittent RCP (I-RCP) with continuous RCP (C-RCP) and HCA alone to determine whether the rate of fluid sequestration can be decreased without losing the beneficial effects of RCP. Eighteen pigs were randomly assigned to undergo 75 min of I-RCP, C-RCP or HCA at 20 degrees C. Hemodynamic and metabolic measurements were carried out for upto 20 h. Behavioral assessments were examined until day 7, when histopathologic analysis of the brain was performed. The median amount of fluid sequestered was 145 ml after C-RCP and -50 ml after I-RCP (p = 0.04). The mean brain weight of the animals that died within the first postoperative day was significantly higher than that in electively sacrificed animals in the C-RCP group (p = 0.04). These data suggest that if RCP is implemented intermittently, the rate of cerebral edema can be decreased, without compromising the benefits of this strategy.

Two different techniques of retrograde cerebral perfusion for thoracic aortic surgery through a left thoracotomy

The authors used profound hypothermic circulatory arrest and continuous retrograde cerebral perfusion for aortic surgery that involved the distal arch through a left thoracotomy. For the first seven patients, oxygenated blood from cardiopulmonary bypass was perfused retrogradely through a venous cannula positioned into the right atrium. In the last 11 cases, venous blood, provided by a perfusion from the lower body, was circulated passively in the brain with the descending aorta clamped. The period of profound hypothermic circulatory arrest was 34.6±11.1 min, and continuous retrograde cerebral perfusion was 31.3±11.1 min. Seventeen patients survived, but there was one early death. Two patients with a severely atherosclerotic aneurysm developed permanent neurological dysfunction. The combination of profound hypothermic circulatory arrest, continuous retrograde cerebral perfusion and open aortic anastomosis through a left thoracotomy protects the brain adequately, and facilitates evacuation of debris and air in the aortic arch. It produces satisfactory results for aortic surgery that involves the distal arch.

Retrograde Cerebral Perfusion for Aortic Arch Surgery in Octogenarians

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.

Three-graft technique for ascending aorta and total aortic arch replacement

We have developed a procedure for total aortic arch replacement using three separate Hemashield grafts and establishing deep hypothermic circulatory arrest and continuous retrograde cerebral perfusion followed by antegrade cerebral perfusion. This method is technically simple and yields secure anastomoses.

Monitoring of regional cerebral oxygenation by near-infrared spectroscopy during continuous retrograde cerebral perfusion for aortic arch surgery.

To assess the value of monitoring of regional cerebral oxygen saturation (rSO2) during aortic arch surgery using continuous retrograde cerebral perfusion (CRCP) in conjunction with profound hypothermic circulatory arrest (HCA). The rSO2 of 12 consecutive patients was monitored non-invasively using near-infrared spectroscopy (NIRS) and the data were analyzed statistically. The mean duration of HCA with CRCP was 62-/+14.1 min. The mean CRCP flow rate was 226+/-163 ml/min. Surgical outcomes were favorable with only a single hospital death (8.3%). However, the rSO2 decreased gradually in all patients during HCA, even combined with CRCP, and fell to 46+/-8.7% on average. It did not change so greatly before HCA and returned finally to its initial level at the end of re-warming. Only one patient developed a permanent neurologic deficit; this patient showed the greatest decrease of rSO2 from 56% to 29% after the longest HCA of 88 min. Two parameters, End-rSO2 (the ratio of post- to pre-HCA rSO2) and delta-rSO2 (the rate of decrease from preto post-HCA rSO2) were obtained since the initial values of rSO2 before surgery differed. There were linear correlations between the CRCP flow rate and each of these two parameters. A multiple regression analysis also revealed a linear equation relating the parameters, which allowed prediction of the safe duration of HCA in different conditions of CRCP and a more favorable adjustment of the CRCP condition in each patient. The study suggests that the combination of HCA and CRCP has a limit of safe duration in spite of its potential usefulness for brain protection, and that rSO2 monitored by NIRS is useful in testing for adequate brain protection. It is hoped that monitoring of rSO2 can facilitate prediction of the safe duration of HCA with CRCP and a more favorable adjustment of CRCP.

Fatal intraoperative pulmonary thrombosis after graft replacement of an aneurysm of the arch and descending aorta in association with deep hypothermic circulatory arrest and aprotinin therapy

J Thorac Cardiovasc Surg 1998;115:723-4

Extracorporeal Circulation for Great Vessels Surgery: A Review of 131 Cases

A retrospective analysis of 131 cases of major vascular surgery, mainly aneurysms of the ascending and descending aorta, was undertaken to determine whether use of different bypass methods chosen according to location of the individual lesions resulted in improved results. For the 93 cases of ascending aortic aneurysm, the method for cardiac protection was improved by the use of continuous retrograde coronary sinus perfusion with cardioplegic blood. In sixteen cases with dissection involving the aortic arch, deep hypothermic circulatory arrest and continuous retrograde cerebral perfusion through the superior vena cava was employed for brain protection. The safe brain circulation arrest time was thus prolonged to the longest record of 81 minutes. Among the group of 93 cases, there were four operative and four hospital deaths, giving a mortality rate of 8.6% (8/93). For the 34 cases of descending aortic aneurysms, left heart bypass was employed to avoid ischemia of the heart, lungs, brain, and the abdominal organs; the operative mortality rate was 8.8% (3/34). In three cases of interrupted aortic arch, separate upper and lower body perfusion under deep hypothermia with low flow rate perfusion for the upper body provided the necessary conditions for radical surgery. In one patient with Budd-Chiari syndrome, a total corrective surgery was achieved under right heart bypass.

Early experience of continuous retrograde cerebral perfusion (CRCP)

Early experience of continuous retrograde cerebral perfusion (CRCP)

Continuous retrograde cerebral perfusion supplies substrates for brain metabolism during hypothermic circulatory arrest.

Ten patients underwent replacement of ascending aorta and/or aortic arch with aneurysm or dissection, using hypothermic circulatory arrest (HCA) with retrograde cerebral perfusion (RCP). RCP was administered through the superior vena cava cannula continuously during HCA (15 degrees C to 20 degrees C). Mean HCA time was 32 minutes (range, 18-45 minutes). To assess the metabolic changes during RCP, blood samples were taken from carotid arteries and the superior vena cava cannula simultaneously, five minutes after the onset and five minutes prior to termination of continuous retrograde cerebral perfusion (CRCP) for analysis of blood gas and glucose level. One patient died intraoperatively due to left ventricular failure. Nine patients survived their operations and all except one with stroke due to partial intimal flap obstruction of innominate artery awoke neurologically intact within four to six hours. One patient died on the postoperative fifth day due to septic shock following resection of ischaemic bowel due to dissection involving the mesenteric artery. Oxygen saturation, pH and glucose level were all found to be lower in blood back-bleeding from the carotid arteries than in blood perfused through the superior vena cava cannula at all sampling times during HCA and CRCP (p < 0.05). Although oxygen and glucose extraction is not only from brain tissue, these data demonstrate the efficacy of CRCP in supplying substrates for brain protection. CRCP is a reliable method as an adjunct to HCA for brain protection.

Case 2—1995 Continuous retrograde cerebral perfusion as an adjunct to brain protection during deep hypothermic systemic circulatory arrest

Case 2—1995 Continuous retrograde cerebral perfusion as an adjunct to brain protection during deep hypothermic systemic circulatory arrest

Protective effect of continuous retrograde cerebral perfusion on the brain during deep hypothermic systemic circulatory arrest.

Deep hypothermic circulatory arrest has been widely used as an adjunct for surgery of the aortic arch to protect the brain and other vital organs. We introduced the use of continuous retrograde cerebral perfusion via the superior vena cava during deep hypothermic circulatory arrest in 1987 and have used it in 33 patients. Continuous retrograde cerebral perfusion times ranged from 10 to 89 minutes (mean 40.2 +/- 22.5), and minimal nasopharyngeal temperatures ranged from 14 to 25 degrees C (mean 17.4 +/- 2.0). Two patients with a ruptured aneurysm died during operation due to bleeding and two other patients, with continuous retrograde cerebral perfusion time of 24 and 35 minutes, died 1 month postoperatively due to preoperative liver cirrhosis and sepsis. Two patients suffered from stroke. The remaining 27 patients, including 6 with from 60 to 82 minutes of continuous retrograde cerebral perfusion, had no complications related to continuous retrograde perfusion. During continuous retrograde cerebral perfusion, 66 pairs of blood samples from the perfusate and from the drainage back to the arch vessels were obtained. Analysis of these samples revealed that partial pressure of oxygen, saturation of oxygen, and oxygen content significantly decreased (p < 0.001), and partial pressure of carbon dioxide (CO2) and CO2 content significantly increased (p < 0.001). The nasopharyngeal temperature gradually increased at the rate of 0.01 to 0.03 degree C/min, but was maintained below 20 degrees C. These results reflect the fact that the aerobic metabolism of the brain is maintained during continuous retrograde cerebral perfusion due to oxygen and substrate availability. This technique offers the potential of metabolic support to the brain during deep hypothermic circulatory arrest and prolongs the safe time limits of deep hypothermic circulatory arrest in surgery of the aortic arch.

Continuous retrograde hypothermic low flow cerebral perfusion during aortic arch surgery

Continuous retrograde hypothermic low flow cerebral perfusion (CRCP) with deep hypothermic systemic circulatory arrest (DHSCA) during aortic arch surgery was employed in six patients, aged 21-79 years. From August 1991 to November 1992, five of these patients were operated for ascending and arch aortic dissection type I, and one patient was operated for an aneurysm extending from the ascending aorta into the arch. Cardiopulmonary bypass (CPB) technology included a centrifugal pump and low-dose aprotinin. Venous drainage was established via the superior and inferior caval veins and arterial return via the femoral artery. Prior to CPB, a bypass line connecting the arterial line with the superior vena cava cannula was implemented. Prior to DHSCA, the patients were systemically cooled to a mean nasopharyngeal temperature of 15.2 degrees C. After induction of systemic circulatory arrest, the femoral artery cannula was clamped. Thereafter, the implemented bypass line was opened to achieve reverse flow into the superior vena cava to allow venoarterial perfusion. The perfusate was returned to the CPB circuit through drainage from the inferior caval vein and by aspiration of blood from the opened aortic arch. CRCP flow rate ranged from 250 to 450 ml/min (mean 375 ml/min) maintaining an internal jugular vein pressure between 18 and 25 mmHg. The duration of CRCP ranged from 24 to 55 minutes (mean 39 minutes). Postoperatively, one patient died of cardiac failure. The other five patients regained full consciousness without neurological deficits, as defined by the Glasgow coma score, within 48 hours after the operation. Neither did we see other major organ complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Continuous retrograde cerebral perfusion during an aortic arch operation

An 81-year-old woman presented with acute aortic regurgitation in the setting of an aneurysm of the ascending aorta and arch. The aortic valve, ascending aorta, and arch were replaced with a composite graft during continuous hypothermic total-body perfusion. Continuous cerebral perfusion was carried out by low-pressure retrograde perfusion via the superior vena cava while perfusion of the lower body was maintained via a femoral arterial cannula.

Continuous retrograde cerebral perfusion for protection of the brain during aortic arch surgery.

Hypothermic circulatory arrest and selective cerebral perfusion for aortic arch surgery have been reported, but these procedures are of limited duration, require hazardous and complicated techniques and can cause clamp injury. Continuous retrograde cerebral perfusion (CRCP) is a new and simple technique for the protection of the brain during hypothermic circulatory arrest. We applied CRCP in 26 patients who underwent aortic arch surgery. Continuous retrograde cerebral perfusion was performed with a mean blood flow of 383 +/- 176, range 120-800, ml/min. The mean duration of CRCP was 63 +/- 15, range 32-92, min with the superior vena cava pressure at 15-42 mm Hg. No neurologic deficit was observed in 20 patients (90%) and only minor deficits in 2 out of the 22 cases without severe postoperative complications, allowing evaluation of the effectiveness of CRCP. Four patients had other severe complications, and the effectiveness of the method could not be evaluated. Continuous retrograde cerebral perfusion can be an excellent and safe technique which avoids clamp injury during aortic arch surgery.

Deep hypothermic systemic circulatory arrest and continuous retrograde cerebral perfusion for surgery of aortic arch aneurysm

From 1987 to February 1991, we have repaired or replaced the aortic arch in ten patients using deep hypothermic systemic circulatory arrest with continuous retrograde cerebral perfusion (CRCP). CRCP can be implemented using the bypass connecting the arterial and venous lines of the extracorporeal circuit to reverse the flow into the superior vena cava cannula after induction of circulatory arrest. CRCP flow required to maintain an internal jugular vein pressure of 20 mmHg ranged from 100 to 500 ml/min. After completion of suturing of the aortic arch graft, air is evacuated retrogradely from the open arch vessels prior to reestablishing the usual arterial return. Two patients died, one from sepsis and the other from liver cirrhosis 1 month postoperatively. CRCP times ranged from 11 to 56 min, and minimal nasopharyngeal temperatures ranged from 16 degrees to 18 degrees C. The difference in oxygen content between the perfused blood and the blood draining from the arch vessels during CRCP most likely reflected the steady-state metabolism of the brain during the deep hypothermic state. This technique offers advantages including the need for dissecting and clamping the arch branches, providing sufficient metabolic support to the brain during deep hypothermia, and eliminating embolism of particulate debris from the aortic arch.