Table 1 - uploaded by Noritsugu Morishige
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We investigated whether the axillary artery or ascending aorta cannulation combined with the arch first method decreases the risk of stroke during total arch replacement.
From January 2002 to January 2006, 35 total arch replacements were performed with the arch first method and central arterial cannulation. The mean age was 66+/-10 years. The cannu...
Contexts in source publication
Context 1
... mean age of the 26 males and 9 females was 6610 years. The preopera- tive states of all cases are shown in Table 1. The preop- erative diagnosis was classified as a true aneurysm in 27 (77%), and an aortic dissection in 8 (23%). ...
Context 2
... and cannulation via a graft in 7 (20%) patients. There were no significant differences between the 2 dif- ferent groups of cannulation sites in term of age, sex, aortic pathology, preoperative comorbidity (Table 1), and con- comitant procedures (Table 2). As depicted in Table 2, no differences were found in aortic cross-clamp time, RCP time, CA time and operative time between the 2 groups. ...
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Citations
... Few researchers took into consideration the atherosclerotic aneurysm diagnosis, based on previous imaging examinations and classification of the type of aneurysm in atherosclerotic, degenerative, chronic dissection and acute dissection. 13,15 Moreover, only Morishige et al. 15 standardized the peripheral arterial cannulation and chose the right axillar artery when an atheromatous plaque or an ulceration of the ascending aorta was detected or when the ascending aorta was dissected. Otherwise central cannulation was employed. ...
... Few researchers took into consideration the atherosclerotic aneurysm diagnosis, based on previous imaging examinations and classification of the type of aneurysm in atherosclerotic, degenerative, chronic dissection and acute dissection. 13,15 Moreover, only Morishige et al. 15 standardized the peripheral arterial cannulation and chose the right axillar artery when an atheromatous plaque or an ulceration of the ascending aorta was detected or when the ascending aorta was dissected. Otherwise central cannulation was employed. ...
... Nowadays, in consequence of the published losses caused by retrograde flow and the possibility of echocardiography in the operating room to avoid false lumen access, its usage has been gradually decreasing. 12,14,15 Therefore, founded on a critical evaluation, it is believed that the greatest concern associated with the arterial cannulation site is related to enhancement issues of the main thoracic aorta surgery centers, which have been improving the surgical techniques in order to reduce complications and to bring the results closer between the groups. ...
Background:
Thoracic aortic surgeries remain with high mortality rates, often associated with postoperative neurological complications. The choice of the right cannulation site is extremely important for suitable blood supply and maintenance of vital functions, especially of the central nervous system.
Objectives:
To compare the influence of central versus peripheral arterial cannulation on neurological outcomes in patients undergoing thoracic aortic surgery through systematic review and meta-analysis.
Methods:
MEDLINE, EMBASE, CENTRAL/CCTR, SciELO, LILACS and reference lists of relevant articles were searched for clinical studies that reported in-hospital neurological outcomes after central or peripheral arterial cannulation during thoracic aortic surgery procedures until December 2013. The principal summary measures were Odds Ratio (OR) for central compared to peripheral arterial cannulation with 95% confidence interval (CI) and p-values considered statistically significant when <0.05. The ORs were combined across studies, using the DerSimonian-Laird random effects model and fixed effects model using the Mantel-Haenszel model--both models were weighted. The meta-analysis was completed using the software Comprehensive Meta-Analysis version 2 (Biostat Inc., Englewood, NJ).
Results:
Six studies were identified and included a total of 4459 patients (1180 for central and 3279 for peripheral cannulation). There was no significant difference between the central and peripheral groups regarding neurological outcomes. The meta-regression evidenced no relationship between neurological outcomes and the variables age, sex, previous coronary event, previous neurological event, urgency surgery, cardiopulmonary bypass time, activated clotting time and esophageal temperature with p > 0,05.
Conclusion:
When it comes to neurological outcomes in patients undergoing thoracic aortic surgery, there was no evidence that argues in favor of any choice of arterial cannulation site, which makes us reject any superiority of one approach over the other in this regard.
... To avoid this devastating complication, perfusion toward the aortic valve has been proposed by several investigations [8,9], but its flow dynamics have not been elucidated. The present study was conducted to quantify the differences in blood flow in the aortic arch produced by perfusion toward the aortic valve or toward the aortic arch and to evaluate whether perfusion toward the aortic valve was able to reduce in-hospital death and postoperative neurologic dysfunction in the patients with atherosclerotic arch aneurysm. ...
... Grooters and colleagues [8] reported perfusion toward the aortic valve eliminates the sandblast effect of the perfusion cannula into the aortic arch and thereby reduces the rate of embolic stroke in CABG patients. Morishige and colleagues [9] reported no postoperative cerebral embolism in 16 patients when this perfusion technique toward the aortic valve in arch operations. Fukuda and colleagues [12] reported that directing the cannula tip of the Dispersion cannula toward the aortic root generated slower and less turbulent flow in the transverse arch of the glass models of both healthy and aneurysmal aortic arches. ...
The study objective was to investigate the efficacy of perfusion toward the aortic valve in patients who had undergone total arch replacement for atherosclerotic arch aneurysms.
Transesophageal echocardiography was used to measure the peak velocities of each perfusion method in the aortic arch. The latest 15 patients with perfusion toward the aortic valve in the arch procedure were compared with 15 patients with perfusion toward the aortic arch in other cardiac operations as controls. Between April 2005 and February 2009, 65 consecutive patients underwent total arch replacement for atherosclerotic aneurysms. Among them, 48 patients underwent operations with perfusion toward the aortic valve and were reviewed.
The peak forward aortic flow velocities with perfusion toward the aortic valve were 48 +/- 26 cm/s before cardiopulmonary bypass and 29 +/- 13 cm/s on cardiopulmonary bypass. The velocities with perfusion toward the aortic arch were 67 +/- 28 cm/s before cardiopulmonary bypass and 226 +/- 114 cm/s on cardiopulmonary bypass (p < 0.001). Of the 48 patients with perfusion toward the aortic valve, postoperative temporary and permanent neurologic dysfunctions occurred in 4 (8.2%) and in 1 (2.0%), respectively. One (2.0%) hospital death occurred.
Perfusion toward the aortic valve resulted in a significant decrease in peak forward aortic flow velocity in the aortic arch during cardiopulmonary bypass, which might reduce the risk of erosion or disruption of existing atheroma and ensuing embolic complications in patients with atherosclerotic aneurysm.
... In spite of these precautions, and with the described use of corrective measures during surgery, they experienced an overall incidence of neurologic complications of 29%; 12% of them classified as permanent deficits, and contributing to early death in 11% of all patients with neurological dysfunction. These results closely parallel the other reports of surgery of acute type A [5]. For a more meticulous analysis it is, in the opinion of this reviewer, not sufficient to report 30-day mortality, because many patients are transferred to chronic care facilities, where their later demise might escape the notice of surgeons involved in primary care. ...
The incidence of embolic events and of cerebral malperfusion in aortic dissection type A (AADA) must be viewed in the context of the existence of a number of possible cannulation techniques. Since femoral cannulation is thought to be associated with a higher risk of perfusion of the false lumen and retrograde embolization, techniques establishing antegrade flow may provide a better option. We describe herein our experience with ascending aortic cannulation in this special patient population.
Between November 1999 and February 2006, 122 patients underwent operation for AADA with arterial access via the dissected ascending aorta. The aorta was cannulated at the site of the minimal distances of the dissected layers. Double purse-string sutures were used to support the cannula. Pressure monitoring in both radial arteries as well as bilateral cerebral oxygen saturation measurement helped to identify malperfusion after establishment of cardiopulmonary bypass. Aortic arch as well as aortic root surgery was performed, as dictated by the pathology. Selective antegrade cerebral perfusion and moderate hypothermia were used for brain and body protection.
Malperfusion occurred in three patients (2.5%). Hospital mortality was 15% for the entire cohort (18 patients). Permanent neurological dysfunction was detected in 15 patients (12%), whereas temporary neurological dysfunction occurred in 21 (17%). Total arch replacement was performed in 31 patients (25%).
Direct cannulation of the ascending aorta is an easy and safe method in patients with AADA. This technique, which also avoids retrograde flow in the downstream aorta, is an alternative to time-consuming axillary artery access.
The success of endovascular therapies for descending thoracic aortic disease has turned attention toward stent graft options for repair of aortic arch aneurysms. Defining the role of such techniques demands understanding of contemporary results of open surgery.
The outcomes of open arch procedures performed on a single surgical service from July 1, 2001 to August 30, 2010, were examined as defined per The Society of Thoracic Surgeons national database.
During the study period, 209 patients (median age, 65 years; range, 26-88) underwent arch operations, of which 159 were elective procedures. In 65 the entire arch was replaced, 22 of whom had portions of the descending thoracic aorta simultaneously replaced via bilateral thoracosternotomy. Antegrade cerebral perfusion was used in 78 patients and retrograde cerebral perfusion in 1. Operative mortality was 2.5% in elective circumstances and 10% in emergency cases (P = .04). The stroke rate was 5.0% when procedures were performed electively and 11.8% when on an emergency basis (P = .11). Procedure-specific mortality rates were 5.5% for elective and 10% for emergency procedures with total arch replacement, and 1.0% for elective and 10% for emergency procedures with hemiarch replacement. Stratified by extent, neurologic event rates were 5.5% for elective and 10% for emergency procedures with total arch and 4.8% for elective and 12.5% for emergency procedures with hemiarch replacement.
Open aortic arch replacement can be performed with low operative mortality and stroke rates, especially in elective circumstances, by a team with particular focus on the procedure. The results of novel endovascular therapies should be benchmarked against contemporary open series performed in such a setting.
