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Selective Aortic Arch Perfusion

Ryan C Shelstad, Justin G Reeves, Katsuhiro Yamanaka, T Brett Reece
We review the operative techniques of aortic arch replacement. Aortic arch replacement presents several formidable challenges, as it requires arresting the circulation to the body and replacement of the brachiocephalic vessels with special consideration for protecting the central nervous system. Perfusion strategies, selective antegrade cerebral perfusion, and operative graft selection are key elements in aortic arch replacement surgery. Standard approaches include the island technique, the branched graft technique, and the "Spielvogel" trifurcated graft technique-each having its own advantages...
October 7, 2016: Seminars in Cardiothoracic and Vascular Anesthesia
Matthew S Mosca, George Justison, T Brett Reece
OBJECTIVE: The optimal strategy to deliver antegrade cerebral perfusion for cerebral protection during hypothermic circulatory arrest has not been established. The purpose of this review was to present our current clinical protocol utilizing selective antegrade cerebral perfusion during aortic arch surgery and to compare it to other published experience. CLINICAL PROTOCOL: Since 2013, our clinical protocol for aortic arch surgery has evolved to using selective antegrade cerebral perfusion via the innominate artery, moderate hypothermia, and ancillary strategies such as goal-directed perfusion (GDP)...
October 14, 2016: Seminars in Cardiothoracic and Vascular Anesthesia
Utpal S Bhalala, Elumalai Appachi, Muhammad Ali Mumtaz
Many known risk factors for adverse cardiovascular and neurological outcomes in children with congenital heart defects (CHD) are not modifiable; however, the temperature and blood flow during cardiopulmonary bypass (CPB), are two risk factors, which may be altered in an attempt to improve long-term neurological outcomes. Deep hypothermic circulatory arrest, traditionally used for aortic arch repair, has been associated with short-term and long-term neurologic sequelae. Therefore, there is a rising interest in using moderate hypothermia with selective antegrade cerebral blood flow on CPB during aortic arch repair...
2016: Frontiers in Pediatrics
Sven Maier, Fabian Kari, Bartosz Rylski, Matthias Siepe, Christoph Benk, Friedhelm Beyersdorf
Open aortic arch replacement is a complex and challenging procedure, especially in post dissection aneurysms and in redo procedures after previous surgery of the ascending aorta or aortic root. We report our experience with the simultaneous selective perfusion of heart, brain, and remaining body to ensure optimal perfusion and to minimize perfusion-related risks during these procedures. We used a specially configured heart-lung machine with a centrifugal pump as arterial pump and an additional roller pump for the selective cerebral perfusion...
September 2016: Journal of Extra-corporeal Technology
Andreas Zierer, Ali El-Sayed Ahmad, Nestoras Papadopoulos, Faisal Detho, Petar Risteski, Anton Moritz, Anno Diegeler, Paul P Urbanski
OBJECTIVE: Surgery for acute type A aortic dissection remains a surgical challenge because of prolonged operative times, bleeding complications, and a considerable risk of neurological morbidity and mortality. The following study investigates the clinical results after surgical treatment for acute type A aortic dissection using selective antegrade cerebral perfusion and moderate-to-mild systemic hypothermia (≥28 °C). METHODS: Between January 2000 and January 2015, 453 consecutive patients underwent surgical treatment for acute type A aortic dissection at two aortic referral centres in Germany...
October 2, 2016: European Journal of Cardio-thoracic Surgery
Levi Bassin, David Bell
The key to aortic surgery is protection of the brain, heart, spinal cord, and viscera. For operations involving the aortic arch, the focus is on cerebral protection, while for pathology involving the descending thoracic aorta, the focus is on spinal protection. Optimal cerebral and spinal protection requires an extensive knowledge of the operative steps and an understanding of the cardiopulmonary bypass modalities that are possible. A bloodless field is required when operating on the aorta. As a result, periods of ischemia to the central nervous system and end-organ viscera are often unavoidable...
September 2016: Best Practice & Research. Clinical Anaesthesiology
Hong Liu, Qian Chang, HaiTao Zhang, CunTao Yu
BACKGROUND: Early mortality and cerebral injury are severe complications of aortic arch surgery, but data from Asian countries are scarce. We reviewed the results of patients who underwent aortic arch replacement with deep hypothermic circulatory arrest (DHCA) and antegrade selective cerebral perfusion (ASCP) at our institution to analyse pre- and intraoperative predictors of early death and neurological complications. METHODS: Clinical data of adult patients who underwent aortic arch surgery with DHCA plus ASCP between January 2005 and December 2011 were retrospectively analysed...
March 5, 2016: Heart, Lung & Circulation
Xian-Yue Wang, Wen-Peng Dong, Guang Tong, Sheng-Hui Bi, Ben Zhang, Hua Lu, Xiao-Wu Wang, Wei-da Zhang
OBJECTIVE: To investigate the protective effects of high-dose ulinastatin on the vital organs in patients undergoing total arch replacement for type A aortic dissection. METHODS: Between September 2014 and March 2016, 66 patients with type A aortic dissection underwent total arch replacement at our center. Thirty-six of the patients received ulinastatin treatment at 300 000 U/8 h from admission to 3 days postoperatively and at 300 000 U/2 h during cardiopulmonary bypass surgery (UTI group), and the other 30 patients did not receive perioperative ulinastatin treatment (control group)...
August 20, 2016: Nan Fang Yi Ke da Xue Xue Bao, Journal of Southern Medical University
Eduard Quintana, Pietro Bajona, Hartzell V Schaff, Joseph A Dearani, Richard Daly, Kevin Greason, Alberto Pochettino
Open aortic arch surgery after coronary artery bypass grafting (CABG) is considered a high-risk operation. We reviewed our surgical approach and outcomes to establish the risk profile for this patient population. In methods, from 2000-2014, 650 patients underwent aortic arch surgery with circulatory arrest. Of these, 45 (7%) had previous CABG. Complete medical record was available for review including all preoperative coronary angiograms and detailed management of myocardial protection. In results, the mean interval from previous CABG to aortic arch surgery was 6...
2016: Seminars in Thoracic and Cardiovascular Surgery
Michael O Kayatta, Edward P Chen
Hypothermic circulatory arrest is a critical component of aortic arch procedures, without which these operations could not be safely performed. Despite the use of hypothermia as a protective adjunct for organ preservation, aortic arch surgery remains complex and is associated with numerous complications despite years of surgical advancement. Deep hypothermic circulatory arrest affords the surgeon a safe period of time to perform the arch reconstruction, but this interruption of perfusion comes at a high clinical cost: stroke, paraplegia, and organ dysfunction are all potential-associated complications...
August 8, 2016: General Thoracic and Cardiovascular Surgery
Mitsumasa Hata, Yukihiko Orime, Shinji Wakui, Tetsuya Nakamura, Rei Hinoura, Kenji Akiyama
OBJECTIVE: We assessed the efficacy of limited proximal arch replacement for type A acute aortic dissection (AAD) with critical complications. METHODS: Sixty-four patients with average age of 64.5 ± 13.0 years, who were intubated prior to arriving at hospital due to cardiopulmonary arrest, cardiac tamponade, or vital organ mal-perfusion, were divided into two groups: group PA consisted of 52 patients undergoing proximal arch repair with mild hypothermic circulatory arrest; group TA consisted of 12 patients who underwent total arch replacement with moderate hypothermia and selective cerebral perfusion...
July 18, 2016: General Thoracic and Cardiovascular Surgery
Hilary P Grocott, Emma Ambrose, Mike Moon
PURPOSE: Selective antegrade cerebral perfusion (SACP) involving cannulation of either the axillary or innominate artery is a commonly used technique for maintaining cerebral blood flow (CBF) during the use of hypothermic cardiac arrest (HCA) for operations on the aortic arch. Nevertheless, asymmetrical CBF with hypoperfusion of the left cerebral hemisphere is a common occurrence during SACP. The purpose of this report is to describe an adjunctive maneuver to improve left hemispheric CBF during SACP by applying extrinsic compression to the left carotid artery...
October 2016: Canadian Journal of Anaesthesia, Journal Canadien D'anesthésie
Yijiang Li, Thierry Siemeni, Joerg Optenhoefel, Andreas Martens, Dietmar Boethig, Axel Haverich, Malakh Shrestha
OBJECTIVES: Operating on the aortic arch is a surgical challenge involving various periods of circulatory arrest. Deep hypothermia is used to protect the brain. Selective antegrade cerebral perfusion (SACP) is employed to protect the brain and enable cerebral ischaemia time to be prolonged. However, there is no standardized SACP protocol. Our centre has performed flow- and pressure-controlled bilateral antegrade cerebral perfusion since 1999. The aim of this study was to investigate the potential relationship between perfusion pressure and neurological outcome, and to examine whether the selective application of higher cerebral perfusion pressure results in better neurological outcomes...
October 2016: Interactive Cardiovascular and Thoracic Surgery
Hironobu Hayashi, Masahiro Okamoto, Hideaki Kawanishi, Toyoaki Matsuura, Nobuoki Tabayashi, Shigeki Taniguchi, Masahiko Kawaguchi
OBJECTIVE: The objective of this study was to evaluate the validity of ocular blood flow measured using laser speckle flowgraphy (LSFG) for the assessment of cerebral perfusion during aortic arch surgery. DESIGN: A prospective study. SETTING: A single university hospital. PARTICIPANTS: The study included 17 patients undergoing aortic arch surgery with cardiopulmonary bypass (CPB) using antegrade selective cerebral perfusion (ASCP)...
June 2016: Journal of Cardiothoracic and Vascular Anesthesia
Andreas Martens, Erik Beckmann, Tim Kaufeld, Julia Umminger, Felix Fleissner, Nurbol Koigeldiyev, Heike Krueger, Jakob Puntigam, Axel Haverich, Malakh Shrestha
OBJECTIVES: Aortic arch surgery is associated with substantial perioperative risks. New prostheses as well as novel perfusion techniques have been developed to reduce the risks of these procedures. The routine application of these new techniques warrants reassessment of risk factors of aortic arch repair. METHODS: Between April 2010 and December 2015, 199 patients [61% male, median age 63 years (interquartile range 52-70 years)] underwent total aortic arch repair in our institution...
May 26, 2016: European Journal of Cardio-thoracic Surgery
Hiroaki Osada, Naoki Kanemitsu, Akihiro Kushiyama, Masashi Kato, Katsuaki Meshii, Motoaki Ohnaka, Hiroyuki Nakajima
We report 2 cases of severe perioperative coronary artery spasm in thoracic aortic surgery. Case 1 was a 72-year-old male with a distal arch aneurysm of 74 mm while case 2 was a 74-year-old male with acute type A aortic dissection. We performed thoracic aortic repair (total arch replacement and ascending aorta replacement) under moderately hypothermic circulatory arrest (25 °C) and selective cerebral perfusion in both cases. ST elevation, abnormal left ventricular wall motion, and hypotension were noted intraoperatively...
May 2016: Kyobu Geka. the Japanese Journal of Thoracic Surgery
Shi Sum Poon, Anthony Estrera, Aung Oo, Mark Field
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether moderate hypothermia circulatory arrest with selective antegrade cerebral perfusion (SACP) is more beneficial than deep hypothermic circulatory arrest in elective aortic arch surgery. Altogether, 1028 papers were found using the reported search, of which 6 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated...
September 2016: Interactive Cardiovascular and Thoracic Surgery
Lei Chen, Rui-Dong Qi, Wei Liu, Cheng-Nan Li, Nan Zhang, Jun-Ming Zhu, Li-Zhong Sun
Background Optimal management of complicated chronic type B dissection with involvement of the distal aortic arch is controversial. Late complications related to thoracic endovascular aortic repair (TEVAR) are much more common than those using open aortic surgery. We reviewed our experience of left subclavian artery (LSCA) transposition with implantation of a stented elephant trunk for complicated chronic type B dissection with involvement of the distal aortic arch. Materials and Methods From January 2011 to June 2015, 20 patients with complicated chronic type B dissection with involvement of the distal aortic arch underwent LSCA transposition with implantation of a stented elephant trunk via a median sternotomy under hypothermic cardiopulmonary bypass with selective antegrade cerebral perfusion (SACP)...
May 13, 2016: Thoracic and Cardiovascular Surgeon
Mohsen Bannazadeh, Rami O Tadros, James McKinsey, Rajiv Chander, Michael L Marin, Peter L Faries
Aortic dissection (AD) is one of the most common catastrophic pathologies affecting the aorta. Anatomic classification is based on the origin of entry tear and its extension. Type A dissections originate in the ascending aorta, whereas the entry tear in Type B dissections starts distal to the left subclavian artery. The patients with aortic dissection who manifest complications such as rupture, malperfusion, aneurysmal degeneration, and intractable pain are classified as complicated AD. Risk factors for developing aortic dissection include age, male gender, and aortic wall structural abnormalities...
April 2016: Surgical Technology International
Ming Gong, Wei-Guo Ma, Xin-Liang Guan, Long-Fei Wang, Jia-Chen Li, Feng Lan, Li-Zhong Sun, Hong-Jia Zhang
BACKGROUND: Continued debates exist regarding the optimal temperature during hypothermic circulatory arrest (HCA) in aortic arch repair for patients with type A aortic dissection (TAAD). This study seeks to examine whether the use of moderate HCA in emergency aortic arch surgery provides comparable operative outcomes to deep HCA for patients with acute TAAD. METHODS: We prospectively enrolled 74 consecutive patients (mean age 47.7±9.8 years, 54 males) with acute TAAD, who underwent emergency total arch replacement and frozen elephant trunk implantation under HCA (18-28 °C) with unilateral selective antegrade cerebral perfusion (uSACP)...
May 2016: Journal of Thoracic Disease
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