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Background: Selective antegrade cerebral perfusion (SACP) is adopted as an alternative to deep hypothermic circulatory arrest (DHCA) during aortic arch surgery. However, there is still no preclinical evidence to support the use of SACP associated with moderate hypothermia (28–30°C) instead of DHCA (18–20°C). The present study aims to develop a reliable and reproducible preclinical model of cardiopulmonary bypass (CPB) with SACP applicable for assessing the best temperature management. Materials and methods: A central cannulation through the right jugular vein and the left carotid artery was performed, and CPB was instituted. Animals were randomized into two groups: normothermic circulatory arrest without or with cerebral perfusion (NCA vs SACP). EEG monitoring was maintained during CPB. After 10 min of circulatory arrest, rats underwent 60 min of reperfusion. After that, animals were sacrificed, and brains were collected for histology and molecular biology analysis. Results: Power spectral analysis of the EEG signal showed decreased activity in both cortical regions and lateral thalamus in all rats during the circulatory arrest. Only SACP determined complete recovery of brain activity and higher power spectral signal compared to NCA (p < 0.05). Histological damage scores and western blot analysis of inflammatory and apoptotic proteins like caspase-3 and Poly-ADP ribose polymerase (PARP) were significantly lower in SACP compared to NCA. Vascular endothelial growth factor (VEGF) and RNA binding protein 3 (RBM3) involved in cell-protection mechanisms were higher in SACP, showing better neuroprotection (p < 0.05). Conclusions: SACP by cannulation of the left carotid artery guarantees good perfusion of the whole brain in this rat model of CPB with circulatory arrest. The present model of SACP is reliable, repeatable, and not expensive, and it could be used in the future to achieve preclinical evidence for the best temperature management and to define the best cerebral protection strategy during circulatory arrest. [ABSTRACT FROM AUTHOR]

The ability to provide antegrade cerebral and systemic perfusion simultaneously may negate the requirement for any prolonged period of circulatory arrest during complex aortic arch reconstruction procedures, depending on the cannulation strategy. We describe the development and successful implementation of a custom 'split arterial line' extracorporeal circuit configuration to facilitate complex aortic surgery. This circuit design offers a wide range of cannulation and perfusion strategies, is safe, adaptable, simple to manage, and avoids the use of roller pumps for blood delivery, which are associated with deleterious haematological complications during prolonged cardiopulmonary bypass cases. The split arterial line approach has now become the standardised methodology for facilitating complex aortic surgery at our institution. [ABSTRACT FROM AUTHOR]

Objectives: Acknowledging lacking of consensus exist in total aortic arch (TAA) surgery for acute type A aortic dissection (AAD), this study aimed to investigate the neurologic injury rate between bilateral and unilateral cerebrum perfusion on the specific population. Methods: A total of 595 AAD patients other than Marfan syndrome receiving TAA surgery since March 2013 to March 2022 were included. Among them, 276 received unilateral cerebral perfusion (via right axillary artery, RCP) and 319 for bilateral cerebral perfusion (BCP). The primary outcome was neurologic injury rate. Secondary outcomes were 30-day mortality, serum inflammation response (high sensitivity C reaction protein, hs-CRP; Interleukin-6, IL-6; cold-inducible RNA binding protein, CIRBP) and neuroprotection (RNA-binding motif 3, RBM3) indexes. Results: The BCP group reported a significantly lower permanent neurologic deficits [odds ratio: 0.481, Confidence interval (CI): 0.296–0.782, p = 0.003] and 30-day mortality (odds ratio: 0.353, CI: 0.194–0.640, p < 0.001) than those received RCP treatment. There were also lower inflammation cytokines (hr-CRP: 114 ± 17 vs. 101 ± 16 mg/L; IL-6: 130 [103,170] vs. 81 [69,99] pg/ml; CIRBP: 1076 [889, 1296] vs. 854 [774, 991] pg/ml, all p < 0.001), but a higher neuroprotective cytokine (RBM3: 4381 ± 1362 vs 2445 ± 1008 pg/mL, p < 0.001) at 24 h after procedure in BCP group. Meanwhile, BCP resulted in a significantly lower Acute Physiology, Age and Chronic Health Evaluation (APACHE) Ⅱscore (18 ± 6 vs 17 ± 6, p < 0.001) and short stay in intensive care unit (4 [3,5] vs. 3 [2,3] days, p < 0.001) and hospital (16 ± 4 vs 14 ± 3 days, p < 0.001). Conclusions: This present study indicated that BCP compared with RCP was associated with lower permanent neurologic deficits and 30-day mortality in AAD patients other than Marfan syndrome receiving TAA surgery. [ABSTRACT FROM AUTHOR]

Coarctation of the aorta is a common congenital abnormality that may be associated with serious and rare anomalies like aneurysms. Severe coarctation or interrupted aortic arch in adults is usually managed by percutaneous interventions or extra-anatomic bypass. However, the presence of an aneurysm beyond the coarcted segment implies the opening of a collateral-rich segment of the aorta with redressal of the arch if hypoplastic. We describe our experience in managing three such patients through antero-lateral thoracotomy with antegrade cerebral perfusion. We have found this technique helpful in treating aneurysms of the distal aortic arch or proximal descending thoracic aorta. [ABSTRACT FROM AUTHOR]

OBJECTIVES The aim of this multicentre study was to demonstrate the safety and clinical performance of E-vita OPEN NEO Stent Graft System (Artivion, Inc.) in the treatment of aneurysm or dissection, both acute and chronic, in the ascending aorta, aortic arch and descending thoracic aorta. METHODS In this observational study of 12 centres performed in Europe and in Asia patients were enrolled between December 2020 and March 2022. All patients underwent frozen elephant trunk using E-vita OPEN NEO Stent Graft System. Primary end point was the rate of all-cause mortality at 30 days and secondary end points included further clinical and safety data are reported up to 3–6 months postoperatively. RESULTS A total of 100 patients (66.7% male; mean age, 57.7 years) were enrolled at 12 sites. A total of 99 patients underwent surgery using the E-vita OPEN NEO for acute or subacute type A aortic dissection (n  = 37), chronic type A aortic dissection (n  = 33) or thoracic aortic aneurysm (n  = 29), while 1 patient did not undergo surgery. Device technical success at 24 h was achieved in 97.0%. At discharge, new disabling stroke occurred in 4.4%, while new paraplegia and new paraparesis was reported in 2.2% and 2.2%, respectively. Renal failure requiring permanent (>90 days) dialysis or hemofiltration at discharge was observed in 3.3% of patients. Between discharge and the 3–6 months visit, no patients experienced new disabling stroke, new paraplegia or new paraparesis. The 30-day mortality was 5.1% and the estimated 6-month survival rate was 91.6% (standard deviation: 2.9). CONCLUSIONS Total arch replacement with the E-vita OPEN NEO can be performed with excellent results in both the acute and chronic setting. This indicates that E-vita OPEN NEO can be used safely, including in the setting of acute type A aortic dissection. [ABSTRACT FROM AUTHOR]

Acute type A aortic dissection (ATAAD) is a surgical emergency with a mortality of 1–2% per hour. Since its discovery over 200 years ago, surgical techniques for repairing a dissected aorta have evolved, and with the introduction of hypothermic circulatory arrest and cerebral perfusion, complex techniques for replacing the entire aortic arch were possible. However, postoperative neurological complications contribute significantly to mortality in this group of patients. The aim of this study was to determine the association between different bilateral selective antegrade cerebral perfusion (ACP) times and the incidence of postoperative ischemic stroke in patients with emergency surgery for ATAAD. Patients with documented hemorrhagic or ischemic stroke, clinical signs of stroke or neurological dysfunction prior to surgery, that died on the operating table or within 48 h after surgery, from whom the postoperative neurological status could not be assessed, and with incomplete medical records were excluded from this study. The diagnosis of postoperative stroke was made using head computed tomography imaging (CT) when clinical suspicion was raised by a neurologist in the immediate postoperative period. For selective bilateral antegrade cerebral perfusion, we used two balloon-tipped cannulas inserted under direct vision into the innominate artery and the left common carotid artery. Each cannula is connected to a separate pump with an independent pressure line. Near-infrared spectroscopy was used in all cases for cerebral oxygenation monitoring. The circulatory arrest was initiated after reaching a target core temperature of 25–28 °C. In total, 129 patients were included in this study. The incidence of postoperative ischemic stroke documented on a head CT was 24.8% (31 patients), and postoperative death was 20.9% (27 patients). The most common surgical technique performed was supravalvular ascending aorta and Hemiarch replacement with a Dacron graft in 69.8% (90 patients). The mean cardiopulmonary bypass time was 210 +/− 56.874 min, the mean aortic cross-clamp time was 114.775 +/− 34.602 min, and the mean cerebral perfusion time was 37.837 +/− 18.243 min. Using logistic regression, selective ACP of more than 40 min was independently associated with postoperative ischemic stroke (OR = 3.589; 95%CI = 1.418–9.085; p = 0.007). Considering the high incidence of postoperative stroke in our study population, we concluded that bilateral selective ACP should be used with caution, especially in patients with severely calcified ascending aorta and/or aortic arch and supra-aortic vessels. All efforts should be made to minimize the duration of circulatory arrest when using bilateral selective ACP with a target of less than 30 min, in hypothermia, at a body temperature of 25–28 °C. [ABSTRACT FROM AUTHOR]

Background: Persistence or recurrence of stenosis is a complication of initial coarctation repair. This study aims to report short‐term outcomes of surgical management of recurrent coarctation and initial repair analysis. Methods: We retrospectively reviewed our experience with 51 patients undergoing recoarctation surgical repair between 2008 and 2019 using antegrade cerebral perfusion (ACP) technique. Results: Surgical correction included prosthetic patch aortoplasty in 23 (45%), resection with wide end‐to‐end anastomosis in 15 (29%), and a tube interposition graft in 13 (25%) patients. The median age at initial correction and reintervention was 12 months and 9 years. The median interval from primary repair to reintervention was 60 months. Initial repair analysis revealed 33% of patients had initial correction in the neonatal period, 72.5% of patients were done via a left thoracotomy approach and 63% of patients had end‐to‐end anastomosis at initial surgery. Conclusion: Our study demonstrates that surgical repair of recurrent coarctation of the aorta using ACP technique can be performed safely and with excellent results. [ABSTRACT FROM AUTHOR]

The "Branch-First total arch replacement" technique has been used extensively in both elective and acute situations, including in type A aortic dissection. The focus of the Branch-First technique is to reduce the risk of neurological and end-organ dysfunction associated with arch replacement by optimising neuroprotection, distal organ perfusion and myocardial protection. The Branch-First technique is a valuable alternative to the frozen elephant trunk (FET) technique in type A aortic dissection, providing a stable landing zone for subsequent interventions on the distal aorta should they be required. Combining the Branch-First technique with FET in appropriate cases can further improve outcomes. We discuss the merits of the Branch-First technique, and contrast them to those of FET techniques for repair of type A aortic dissection. [ABSTRACT FROM AUTHOR]

Our current approach towards total arch replacement includes the following: (1) innominate vein mobilization, (2) no neck vessel taping, and no dissection of the vagal nerve, (3) meticulous selection of arterial cannulation site and type of arterial cannula, (4) antegrade cerebral perfusion(ACP)for neuro-protection, utilizing three balloon-tipped cannular from inside the arch, (5) whole-body hypothermia with minimal tympanic temperatures between 20 and 23 °C and minimal rectal temperatures below 30 °C, (6) distal enucleation and felt reinforcement for in zone III distal anastomosis using four branched graft, (7) early re-warming after distal anastomosis with ACP flow adjustment while monitoring brain oxygenation by near-infrared spectroscopy (NIRS) and (8) second anastomosis is proximal and last one is arch vessel reconstruction, (9) maintaining strict fluid balance below 1000 ml by the extracorporeal ultrafiltration method (ECUM) during cardiopulmonary bypass (CPB), with the expectation of more rapid pulmonary functional recovery. [ABSTRACT FROM AUTHOR]

There is considerable debate with regard to the optimal cerebral protection strategy during aortic arch surgery. There are three contemporary techniques in use which include straight deep hypothermic circulatory arrest (DHCA), DHCA with retrograde cerebral perfusion (DHCA + RCP), and moderate hypothermic circulatory arrest with antegrade cerebral perfusion (MHCA + ACP). Appropriate application of these methods ensures appropriate cerebral, myocardial, and visceral protection. Each of these techniques has benefits and drawbacks and ensuring coordinated circulation management strategy is critical to safe performance of aortic arch surgery. In this report, we will review various cannulation strategies, review logistics of hypothermia, and review the relevant literature to outline the strengths and weaknesses of these various cerebral protection strategies. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES There have been limited data available regarding aortic arch replacement in dialysis patients. The purpose of this study was to examine real-world data and to determine the impact of preoperative dialysis status and other risks on surgical aortic arch replacement using the Japan Cardiovascular Surgery Database. METHODS A total of 5044 patients who underwent elective, isolated aortic arch replacement using antegrade cerebral perfusion during 2014–2017 were eligible for the study. Of these, 89 patients received haemodialysis preoperatively. The patients were divided into 6 groups according to their preoperative estimated glomerular filtration rate and dialysis status for comparison. Preoperative and postoperative data were examined using a multivariable regression model. RESULTS The overall surgical mortality rates of non-Chronic Kidney Disease (CKD) (estimated glomerular filtration rate >60 ml/min/1.73 m2), stage 3A, stage 3B, stage 4, stage 5 CKD and dialysis patients were 2.6%, 3.1%, 6.8%, 11.6%, 16.7% and 13.5%, respectively. After risk adjustment, dialysis was shown to be strongly associated with surgical mortality (odds ratio 4.39 and 95% confidence interval 2.22–8.72) and have a trend to be associated with postoperative stroke (odds ratio 2.02, 95% confidence interval 1.00–4.10, P  = 0.051) when compared to the non-CKD group. As predictors of mortality, male sex, peripheral arterial disease, preoperative liver dysfunction and impaired left ventricular function were identified. CONCLUSIONS The Japanese nationwide database revealed the outcomes of aortic arch replacement in dialysis patients. Appropriate counselling and an alternative strategy should be considered for such patients with multiple risks for mortality. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES The risk of brain injury following surgery for type A aortic dissection (TAAD) remains substantial and no consensus has still been reached on which neuroprotective technique should be preferred. We aimed to investigate the association between neuroprotective strategies and clinical outcomes following TAAD repair. METHODS Using the UK National Adult Cardiac Surgical Audit, we identified 1929 patients undergoing surgery for TAAD (2011–2018). Deep hypothermic circulatory arrest (DHCA) only, unilateral (uACP), bilateral antegrade cerebral perfusion (bACP) and retrograde cerebral perfusion were used in 830, 117, 760 and 222 patients, respectively. The primary end point was a composite of death and/or cerebrovascular accident (CVA). Generalized linear mixed model was used to adjust the effect of neuroprotective strategies for other confounders. RESULTS The use of bACP was associated with longer circulatory arrest (CA) compared to other strategies. There was a trend towards lower incidence of death and/or CVA using uACP only for shorter CA. In particular, primary end point rate was 27.7% overall and 26.5%, 12.5%, 28.0% and 22.9% for CA <30 min and 28.6%, 30.4%, 33.3% and 33.0% for CA ≥30 min with DHCA only, uACP, bACP and retrograde cerebral perfusion, respectively. The use of DHCA only was associated with five-fold [odds ratio (OR) 5.35, 95% confidence interval (CI) 1.36–21.02] and two-fold (OR 1.77, 95% CI 1.01–3.09) increased risk of death and/or CVA compared to uACP and bACP, respectively, but the effect of uACP was significantly associated with CA duration (hazard ratio 0.97, 95% CI 0.94–0.99; P  = 0.04). CONCLUSIONS In TAAD repair, the use of uACP and bACP was associated with a lower adjusted risk of death and/or CVA when compared to DHCA. uACP can offer some advantage but only for a shorter CA duration. [ABSTRACT FROM AUTHOR]

Background: Cardiopulmonary bypass (CPB) may lead to tissue hypoxia, inflammatory response, and risk for acute kidney injury (AKI). We evaluated the prevalence of AKI and inflammatory response in neonates undergoing heart surgery requiring CPB with or without antegrade cerebral perfusion (ACP).Methods: Forty neonates were enrolled. The patients were divided into two groups depending on the use of ACP. AKI was classified based on the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Inflammatory response was measured using plasma concentrations of interleukins 6 (IL-6) and 10 (IL-10), white blood cell count (WBC), and C-reactive protein (CRP).Results: Eight patients (20%) experienced AKI: five (29%) in the ACP group and three (13%) in the non-ACP group (P = 0.25). Postoperative peak plasma creatinine and urine neutrophil gelatinase-associated lipocalin were significantly higher in the ACP group than in the non-ACP group [46.0 (35.0-60.5) vs 37.5 (33.0-42.5), P = 0.044 and 118.0 (55.4-223.7) vs 29.8 (8.1-109.2), P = 0.02, respectively]. Four patients in the ACP group and one in the non-ACP group required peritoneal dialysis (P = 0.003). Postoperative plasma IL-6, IL-10, and CRP increased significantly in both groups. There were no significant differences between the ACP and non-ACP groups in any of the inflammatory parameters measured.Conclusions: No significant difference in the AKI occurrence or inflammatory response related to CPB modality could be found. In our study population, inflammation was not the key factor leading to AKI. Due to the limited number of patients, these findings should be interpreted with caution. [ABSTRACT FROM AUTHOR]

Background: Wilms' tumor is the most common pediatric renal tumor. Almost half of all cases have involvement of the inferior vena cava, which must be addressed at the time of surgical excision. Further extension into the right atrium may pose an immediate vital risk and necessitates special operative techniques that employ cardiopulmonary bypass. Case Report: We report the case of a child with a left Wilms' tumor with inferior caval and right atrial involvement, which led to significant hemodynamic compromise and urgent surgery. A left nephrectomy and cavoatrial thrombectomy were performed via a sterno-laparotomy. Our strategy employed moderate hypothermic circulatory arrest at 26°C and antegrade cerebral perfusion in order to improve visualization and ensure complete thrombectomy and protection of the abdominal organs. Conclusion: This case emphasizes the advantages of moderate hypothermic circulatory arrest compared to deep hypothermic circulatory arrest and normothemic cardiopulmonary bypass. [ABSTRACT FROM AUTHOR]

Objectives: Antegrade cerebral perfusion (ACP) under moderate hypothermic circulatory arrest is used during total aortic arch replacement surgery (TARS) in patients with acute type A aortic dissection, but it is associated with high mortality and morbidity. We hypothesized that combining ACP with retrograde inferior vena caval perfusion (RIVP) improves outcomes.Methods: This pilot study was prospective, randomized, controlled and assessor-blinded. Patients scheduled for TARS were randomly treated with either ACP or RIVP + ACP. The primary outcome was a composite of mortality and major complications including paraplegia, postoperative renal failure, severe liver dysfunction, and gastrointestinal complications. Secondary outcomes included neurological complications, length of intubation and requirement of blood products.Results: A total of 76 patients were recruited (n = 38 per group). Primary outcome occurred in 23 patients (61%) in the ACP group and 16 (42%) in the RIVP + ACP group (OR: 0.60, 95% CI: 0.21-1.62; p = 0.31). There was a lower incidence of transient neurological deficits in the RIVP + ACP group (26% vs. 58%, OR: 0.26; 95% CI: 0.10-0.67,p = 0.006;). The RIVP + ACP group underwent shorter intubation (25 vs 47 h, p = 0.022) and required fewer blood products (red cells, 3.8 units vs 6.5 units, p = 0.047; platelet: 2.0 units vs 2.0 units, p = 0.023) compared with the ACP group.Conclusions: RIVP + ACP may be associated with lower incidence of transient neurological deficits, shorter intubation and less blood transfusion requirement than ACP alone during TARS. Multi-center, randomized trials with larger samples are required to determine whether RIVP + ACP is associated with lower rates of mortality and major complications.Trial Registration: Pilot study of a RCT registered in clinicaltrials.gov (NCT03607786), Registered 30 July, 2018-Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03607786 . [ABSTRACT FROM AUTHOR]

Background: We designed a prospective randomized clinical study to compare unilateral and bilateral antegrade cerebral perfusion (ACP) under moderate hypethermia in open distal aortic hemiarch replacement in ascending aortic aneurysm. Methods: Forty‐two patients were prospectively randomized into two groups; unilateral ACP to Group 1 and bilateral ACP to Group 2. Inclusion criteria were pathological aortic aneurysm in the ascending aorta and/or aortic arch, elective operation, normal preoperative carotid Doppler ultrasonography, and nonexistence of preoperative neurological event. Patients were evaluated with preoperative and postoperative biochemical blood analysis, magnetic resonance imaging (MRI), and neurological disorders. The primary endpoints were permanent neurological disorder and death. Results: There were 21 patients in each group. Mean age was 56.57 ± 10.06 years in Group 1 and 50.95 ± 15.64 years in Group 2 (p =.170). No significant difference was found according to demographic data. ACP times were significantly higher in bilateral ACP (Group 1: 12.62 ± 5.04 min, Group 2: 18.23 ± 9.04 min, p =.018) whereas cross‐clamp time and cardiopulmonary bypass times were not (p =.693 and p =.584 sequentially). Transient neurological disorder was found in seven patients in Group 1 and in 4 patients in Group 2 (p =.484). Postoperative MRI revealed new milimetric ischemic zones in three patients in Group 1 but none in Group 2. No permanent neurological disorder or mortality was seen. Conclusion: The present randomized clinical prospective study could not prove the superiority of one of the technique in cerebral protection probably because, our overall ACP time was too short. [ABSTRACT FROM AUTHOR]

We present a case of antegrade cerebral perfusion based on a circuit with a centrifugal pump for general open-heart surgery to achieving cerebral protection during a challenging hybrid aortic arch repair. [ABSTRACT FROM AUTHOR]

Keywords: Cerebral protection; Aortic arch surgery; Antegrade cerebral perfusion EN Cerebral protection Aortic arch surgery Antegrade cerebral perfusion 1 2 2 07/04/23 20230601 NES 230601 Lack or shortage of oxygen delivery leads to organ damage. Cerebral oxygen delivery is a function of cerebral blood flow (CBF) and blood oxygen content, whereby the CBF is dependent on cerebral perfusion pressure and inversely proportional to cerebrovascular resistance. Perioperative cerebral perfusion in aortic arch surgery: a potential link with neurological outcome. [Extracted from the article]

Objective To determine which of antegrade and retrograde cerebral perfusion (ACP and RCP) surpasses for a reduction in postoperative incidence of neurological dysfunction and all-cause death in thoracic aortic surgery, we performed a meta-analysis of contemporary comparative studies. Methods MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched from January 2010 to June 2017. For each study, data regarding the endpoints in both the ACP and RCP groups were used to generate odds ratios (ORs) and 95% confidence intervals (CIs). Study-specific estimates were combined using inverse variance-weighted averages of logarithmic ORs in the fixed-effect model. Results We identified and included 19 eligible studies with a total of 15,365 patients undergoing thoracic aortic surgery by means of ACP (a total of 7,675 patients) or RCP (a total of 7,690 patients). Pooled analysis demonstrated no statistically significant differences in postoperative incidence of stoke (17 studies enrolling a total of 9,421 patients; OR, 0.92; 95% CI, 0.79–1.08; p = 0.32) and mortality (16 studies including a total of 14,452 patients; OR, 1.07; 95% CI, 0.90–1.26; p = 0.46) between ACP and RCP, whereas a trend toward a significant reduction in incidence of temporary neurological dysfunction (TND) for ACP (12 studies enrolling a total of 7922 patients; OR, 0.85; 95% CI, 0.69–1.04; p = 0.12) was found. Conclusion In thoracic aortic surgery, postoperative incidence of stroke and mortality was similar between ACP and RCP, whereas a trend toward a reduction of TND incidence existed in ACP. [ABSTRACT FROM AUTHOR]

Aortic aneurysms in childhood are rare disease entities and are usually seen in patients with genetic connective tissue disorders such as Marfans, Ehler-Danlos, and Loeys-Dietz syndrome (LDS). Patients affected with LDS present early in life and have a rapid disease progression. We report a case of repair of an ascending and aortic arch aneurysm in an infant with Loeys-Dietz syndrome. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Optimal cerebral and visceral protection is crucial in aortic arch surgery. The main method for this protection has traditionally been deep hypothermic circulatory arrest (DHCA). Recently, antegrade cerebral perfusion with moderate hypothermia has become the preferred strategy for adult patients and some children undergoing aortic arch surgery. Continuous cerebral perfusion should reduce the incidence of neurological complications, but the degree of damage to organs and systems resulting from the lack of blood flow distal to the aortic arch remains unclear. Here, we aimed to evaluate the efficacy and safety of methods of protecting the brain and internal organs during aortic arch surgery in infants. METHODS: We performed a retrospective review of 62 patients who underwent aortic arch reconstruction to assess their neurological status and internal injuries after different methods of cerebral protection. RESULTS: Surgical correction of aortic arch congenital abnormalities was performed under DHCA in 27 patients (Group I), and unilateral selective antegrade cerebral perfusion (SACP) was performed in 35 patients (Group II). In Group I, 30.8% of patients had neurological complications, whereas in Group II 5.9% had neurological complications. The odds ratio for a neurological event was significantly lower in Group II compared with Group I--0.14 [(95% CI 0.02-0.63), P = 0.02]. However, incidence of renal dysfunction was significantly higher in the second group than the first: 21 (61.2%) vs 5 (19.2%) cases, respectively [odds ratio 6.49 (95% CI 1.41-38.26), P = 0.02]. CONCLUSIONS: Aortic arch reconstruction accompanied by SACP has a lower risk of neurological complications compared with DHCA. However, the high incidence of renal complications with SACP requires further study. [ABSTRACT FROM AUTHOR]

Aortic arch surgery has become increasingly complex, and novel surgical approaches have been utilized. Efforts aimed at improving neurological outcomes in this patient population have been numerous, with varying degrees of success. This article summarizes the anesthetic considerations for procedures on the aortic arch, including evidence-based outcomes with respect to temperature management, perfusion strategies, hemodynamic goals, adjunct agents, and neuromonitoring. [ABSTRACT FROM PUBLISHER]

We describe a simplified 3-way perfusion strategy that could be used in complex aortic procedures, which ensures continuous end-organ perfusion and minimizes the potential risks of cardiac, cerebral and peripheral ischaemic complications. [ABSTRACT FROM PUBLISHER]

The article presents a study aimed at assessing the reliability of the commonly used core body temperature measurement sites in modern aortic surgery performed with the aid of hypothermic circulatory arrest (HCA) and selective antegrade cerebral perfusion (ACP). It is concluded that tympanic temperature measurements correlate with arterial blood temperature monitoring during aortic surgery with HCA and ACP and thus, should replace bladder and rectal measurements.

Introduction: Deep hypothermic circulatory arrest for adult aortic arch repair is still associated with significant mortality and morbidity. Furthermore, there is still significant variation in the conduct of this complex perioperative technique. This variation in deep hypothermic circulatory arrest practice has not been adequately characterized and may offer multiple opportunities for outcome enhancement. The hypothesis of this study was that the current practice of adult deep hypothermic circulatory arrest in China has significant variations that might offer therapeutic opportunities for reduction of procedural risk. Methods: An adult deep hypothermic circulatory arrest questionnaire was developed and then administered at a thoracic aortic session at the International Cardiothoracic and Vascular Anesthesia Congress convened in Beijing during 2010. The data was abstracted and analyzed. Results: The majority of the 56 respondents were anesthesiologists based in China at low-volume deep hypothermic circulatory arrest centers. The typical aortic arch repair had a prolonged deep hypothermic circulatory arrest time at profound hypothermia. The target temperature for deep hypothermic circulatory arrest was frequently measured distal to the brain. The most common perfusion adjunct was antegrade cerebral perfusion, typically monitored with radial arterial pressure and cerebral venous oximetry. The preferred neuroprotective agents were steroids and propofol. Conclusions: The identified opportunities for outcome improvement in this delineated deep hypothermic circulatory arrest model include nasal/tympanic temperature measurement and routine cerebral perfusion, preferably with unilateral antegrade cerebral perfusion monitored with radial artery pressure and cerebral oximetry. Development and dissemination of an evidence-based consensus would enhance these practice-improvement opportunities. [ABSTRACT FROM AUTHOR]

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The aim of this study is to compare cerebral protection using antegrade cerebral perfusion (ACP) with various flow rates during deep hypothermic circulatory arrest (DHCA) in a piglet model. Twenty-three piglets were randomized to five groups: the control group ( n = 3), DHCA group ( n = 5), ACP25 group ( n = 5), ACP50 group ( n = 5), and ACP80 group ( n = 5). Three control piglets did not undergo operations. Twenty piglets underwent cardiopulmonary bypass (CPB) and DHCA for 60 min at 20°C. ACP was conducted at 0, 25, 50, and 80 mL/kg/min in the DHCA, ACP25, ACP50, and ACP80 group, respectively. Serum S-100B protein and neuron-specific enolase were monitored, and brain tissues were assayed for the activities of caspase-3 and stained for the evidence of apoptotic cellular injury. Rise in serum S-100B level (post-CPB-pre-CPB) in the ACP50 group was significantly lower than that in the ACP80 group ( P = 0.001). Caspase-3 levels were significantly elevated in the ACP80 group compared with the ACP25 ( P = 0.041) and ACP50 group ( P = 0.01), while positive terminal deoxyneucleotidyl transferase-mediated biotin-dUTP nick end labeling reaction scores in the ACP80 group were significantly higher than those in the ACP25 ( P = 0.043) and ACP50 group ( P = 0.023). Cerebral protection effects of ACP at 25 and 50 mL/kg/min were superior to that of ACP at 80 mL/kg/min as determined by cerebral markers, immunology, and histology. [ABSTRACT FROM AUTHOR]

Deep hypothermic circulatory arrest is an essential tool in the surgeon’s armamentarium. There are essentially three strategies to address cerebral ischemia during arrest periods. Early surgical case series pioneered the option of complete anoxia with deep hypothermia. Subsequent innovators introduced the concept of retrograde perfusion of the cerebral vessels through the venous system, and others have advocated the use of selective and non-selective antegrade perfusion of the cerebral arteries. Clinical studies assessing outcomes of the three approaches are compromised by small patient numbers, retrospective design and surgeon bias.In this review, the authors will briefly discuss the conceptual basis of these strategies and the literature comparing these approaches in terms of key neurologic outcomes. The importance of this topic will emphasize the key role the perfusion community plays in establishing guidelines for best practice in circulatory arrest to go forward with education and research in this area. [ABSTRACT FROM PUBLISHER]

The aim of this study is to evaluate the effect of temperature on cerebral oxygen metabolism at total body flow bypass and antegrade cerebral perfusion (ACP). Neonatal piglets were put on cardiopulmonary bypass (CPB) with the initial flow rate of 200 mL/kg/min. After cooling to 18°C ( n = 6) or 25°C ( n = 7), flow was reduced to 100 mL/kg/min (half-flow, HF) for 15 min and ACP was initiated at 40 mL/kg/min for 45 min. Following rewarming, animals were weaned from bypass and survived for 4 h. At baseline, HF, ACP, and 4 h post-CPB, cerebral blood flow (CBF) was measured using fluorescent microspheres. Cerebral oxygen extraction (CEO) and cerebral metabolic rate of oxygen (CMRO) were monitored. Regional cranial oxygen saturation (rSO) was continuously recorded throughout the procedure using near-infrared spectroscopy. At 18°C, CBF trended lower at HF and ACP and matched baseline after CPB. CEO trended lower at HF and ACP, and trended higher after CPB compared with baseline. CMRO at ACP matched that at HF. Cranial rSO was significantly greater at HF and ACP ( P < 0.001, P < 0.001) and matched baseline after CPB. At 25°C, CBF trended lower at HF, rebounded and trended higher at ACP, and matched baseline after CPB. CEO was equal at HF and ACP and trended higher after CPB compared with baseline. CMRO at ACP was greater than that at HF ( P = 0.001). Cranial rSO was significantly greater at HF ( P = 0.01), equal at ACP, and lower after CPB ( P = 0.03). Lactate was significantly higher at all time points ( P = 0.036, P < 0.001, and P < 0.001). ACP provided sufficient oxygen to the brain at a total body flow rate of 100 mL/kg/min at deep hypothermia. Although ACP provided minimum oxygenation to the brain which met the oxygen requirement, oxygen metabolism was altered during ACP at moderate hypothermia. ACP strategy at moderate hypothermia needs further investigation. [ABSTRACT FROM AUTHOR]

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We describe the repair of a root, ascending aortic and arch aneurysm in a 69-year-old man with a bioprosthetic Shelhigh conduit and cylinder, employing continuous bilateral antegrade cerebral perfusion through an anomalous innominate artery with a bovine arch variant anatomy. The origin of both the innominate artery and the left common carotid artery from a common stem from the arch in this bovine arch variant puts the whole cerebral circulation at risk, on one hand, yet provides an opportunity of continuous bilateral antegrade cerebral perfusion through the right brachial, right axillary, right subclavian or innominate artery, during arch reconstruction under lower body, deep hypothermic circulatory arrest. Safety and adequacy of selective cerebral perfusion through the right axillary artery in patients with normal arch vessel origin depends on an intact circle of Willis. In this bovine arch variant, both cerebral hemispheres can be perfused through the right brachial, right axillary, right subclavian or the innominate artery, independent of the integrity of the circle of Willis, because of the origin of the left common carotid artery from the innominate artery, except for the area supplied by the left vertebral artery. Although this is the first report of innominate artery perfusion for arch reconstruction for aneurysm in a bovine arch variant, we believe the method described has important implications for cerebral protection in light of the generally reported incidence of bovine arch from 13 to 35 percent. [ABSTRACT FROM AUTHOR]

Surgery of the aortic arch is a great challenge in cardiovascular surgery. Its partial or total replacement demands the temporary interruption of normal cerebral perfusion, with associated potential for neurological injury. Three methods of cerebral protection have been applied between 1975 and today: hypothermic circulatory arrest as a basic method, either alone or with antegrade cerebral perfusion (ACP), or retrograde cerebral perfusion (RCP) as an adjunctive method. After extensive research regarding the controversies that surround the ideal method of cerebral protection, it is obvious that ACP is superior to RCP for brain protection. ACP obtains a near-physiologic brain perfusion, with homogenous distribution of blood throughout the capillary beds, and extends, the safe time of hypothermic circulatory arrest ot 80 min, allowing the completion of whatever aortic arch work is necessary. By contrast, RCP perfuses a smaller brain territory than ACP, approximately 10-20%. Hence, RCP is, in our opinion, a 'smaller adjunct' to brain protection than ACP. Detailed evidence and future directions for further research are discussed. [ABSTRACT FROM AUTHOR]

Background and objective: To prevent neurological complications, low-flow antegrade cerebral perfusion (ACP) is used during repair of complex congenital heart defects. To overcome technical problems, continuous monitoring of cerebral blood flow and oxygenation is mandatory. The aim of the study was to evaluate the effect of different ACP flow rates on cerebral oxygen saturation obtained by near infrared spectroscopy. Methods: Ten consecutive neonates undergoing Norwood stage I were included. In addition to near infrared spectroscopy (Invos 5100; Somanetics Corp., USA) on both hemispheres, mean arterial pressure and transcranial Doppler flow velocity were measured continuously and arterial and jugular venous oxygen saturation intermittently. Cerebral oxygen extraction ratio was calculated. Measurement points were obtained after starting bypass, during ACP with flow rates of 30, 20 and 10 mL kg-1 min-1 and immediately after ACP. ANOVA and Tukey-Kramer multiple comparison test were used for statistics. Results: The near infrared spectroscopy signal could be obtained in all children at all measurement points, whereas transcranial Doppler failed in 1 neonate at a flow rate of 30 mL kg-1min-1, in 3 neonates at 20 mL kg-1min-1 and in 4 neonates at 10 mL kg-1min-1. With the reduction of flow there was a significant decrease of cerebral oxygen saturation on both hemispheres (right: 78 ± 8 to 72 ± 9 and 66 ± 8, P « 0.001; left: 71 « 7 to 65 « 7 and 60 ± 7, P « 0.001), of jugular venous oxygen saturation (94 ± 6 to 89 ± 13 and 83 ± 15, P « 0.001) and a significant increase in oxygen extraction ratio (9.1 ± 8 to 14.8 ± 14 and 21 ± 16, P « 0.001) respectively, for 30, 20, 10 mL kg-1min-1. Conclusion: Near infrared spectroscopy reliably detects flow alterations during ACP with profound hypothermia. [ABSTRACT FROM AUTHOR]

Background: During total aortic arch replacement surgery (TARS) for patients with acute type A aortic dissection, the organs in the lower body, such as the viscera and spinal cord, are at risk of ischemia even when antegrade cerebral perfusion (ACP) is performed. Combining ACP with retrograde inferior vena caval perfusion (RIVP) during TARS may improve outcomes by providing the lower body with oxygenated blood.Methods: This study is designed as a multicenter, computer-generated, randomized controlled, assessor-blind, parallel-group study with a superiority framework in patients scheduled for TARS. A total of 636 patients will be randomized on a 1:1 basis to a moderate hypothermia circulatory arrest (MHCA) group, which will receive selective ACP with moderate hypothermia during TARS; or to an RIVP group, which will receive the combination of RIVP and selective ACP under moderate hypothermia during TARS. The primary outcome will be a composite of early mortality and major complications, including paraplegia, postoperative renal failure, severe liver dysfunction, and gastrointestinal complications. All patients will be analyzed according to the intention-to-treat protocol.Discussion: This study aims to assess whether RIVP combined with ACP leads to superior outcomes than ACP alone for patients undergoing TARS under moderate hypothermia. This study seeks to provide high-quality evidence for RIVP to be used in patients with acute type A aortic dissection undergoing TARS.Trial Registration: Clinicaltrials.gov, ID: NCT03607786 . Registered on 30 July 2018. [ABSTRACT FROM AUTHOR]