Interactive Cardiovascular and Thoracic Surgery 3:621-630(2004)
© 2004 European Association of Cardio-Thoracic Surgery
Best evidence topic - Cardiac general |
In aortic arch surgery is there any benefit in using antegrade cerebral perfusion or retrograde cerebral perfusion as an adjunct to hypothermic circulatory arrest?
James Barnarda,
Joel Dunningb,*,
Michael Grossebnera and
Mohamad N. Bittarc
a Department of Cardiothoracic Surgery, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
b Department of Cardiothoracic Surgery, Freeman Hospital, Freeman Road, Newcastle upon Tyne, UK
c Department of Cardiothoracic Surgery, Wythenshawe Hospital, Southmoor Road, Manchester M23 9LT, UK
* Corresponding author. Tel./fax: +44 780 154 8122. (E-mail: joeldunning{at}doctors.org.uk).
Received July 12, 2004;
accepted July 13, 2004
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Abstract
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A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was whether patients having aortic arch surgery benefit from antegrade or retrograde cerebral perfusion in addition to hypothermic circulatory arrest to reduce neurological injury or mortality. Altogether 408 papers were found using the reported search, of which 16 presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that antegrade cerebral perfusion is superior as an adjunct to hypothermic circulatory arrest when compared to retrograde cerebral perfusion or hypothermic circulatory arrest alone, although clinical evidence for this from prospective clinical trials is weak.
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1. Introduction
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A best evidence topic was constructed according to a structured protocol. This protocol is fully described in the ICVTS [1].
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2. Clinical scenario
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You are about to perform surgery on a 65-year-old gentleman with an acute aortic dissection. He was admitted through the accident and emergency department with acute chest pain. His chest X-ray showed a widened mediastinum and he underwent a computerised tomography scan of his chest which confirmed the diagnosis of a type 1 aortic dissection. He is a smoker and has a previous history of a transient ischaemic attack. A carotid Doppler scan performed at that time showed mild to moderate bilateral internal carotid artery disease and surgery was not indicated. The patient is stable but surgery is inevitable to save this patient's life. You plan your surgery and you think about the best method of protecting his brain during the circulatory arrest period. You consult two colleagues about the optimal method of cerebral protection. One surgeon tells you that retrograde cerebral perfusion is a quick and easy way to ensure good cerebral protection. A second surgeon tells you that there is no evidence that this works at all and none of the perfusate actually gets to the brain with this method. He tells you that there is no substitute for quick stitching! You elect to look up the evidence.
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3. Three part question
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In patients having [aortic arch surgery] can [antegrade cerebral perfusion (ACP) or retrograde cerebral perfusion (RCP)] reduce [neurological injury or mortality]?
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4. Search strategy
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[aortic surgery.mp OR aortic arch.mp OR aortic dissection.mp OR exp aortic aneurysm] AND [cerebral protection.mp OR cerebral protection.mp OR brain protection.mp OR brain perfusion.mp OR RCP.mp OR ACP.mp OR SCP.mp] LIMIT to English.
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5. Search outcome
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Using the above search 408 papers were found with a further three papers found by checking the references of relevant papers. Relevant papers numbered 26 of which 4 were out of scope and 9 were rejected on the basis of poor methodology. Only 16 papers were reviewed in full. Clinical studies are listed in Table 1. In addition, Table 2 lists animal experimental studies that were felt to be of relevance. In terms of clinical studies several early studies supporting the efficacy of retrograde cerebral perfusion were found which were rejected because they were retrospective cohort studies with no objective assessment of neurological injury.
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6. Results
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Two prospective randomized controlled trials (PRCTs) comparing ACP and RCP were found [2,3]. These both favoured ACP over RCP with varying strengths of evidence. Okita et al. [2] performed a PRCT comparing RCP against selective antegrade cerebral perfusion (SCP) with 30 patients in each group. Due to the small numbers in each cohort there were no statistically significant outcomes in terms of mortality, stroke, S-100b values or cognitive impairment. However, transient brain dysfunction was higher in the RCP group, with 10 patients in the RCP group compared to only 4 in the SCP group suffering dysfunction. Tanoue et al. [3] performed a PRCT comparing middle cerebral artery blood flow velocities in 32 patients having elective repair of an aortic arch aneurysm and demonstrated much better flow in the middle cerebral artery with the SCP strategy than with RCP. Despite this they continue to use RCP in their daily practise. Neri et al. [4] assessed cerebral autoregulation of blood flow in elective patients having aortic arch surgery and took this as a measure of cerebral protection. In this non-randomized prospective study they were able to demonstrate that there is a benefit to the use of ACP, however, the observational nature of this study where different surgeons utilized different techniques may have introduced bias.
Among the cohort studies, Higami et al. [5] demonstrated significantly better cerebrovascular oxygen saturation in the SCP group when compared to the RCP group with the use of near infrared spectroscopy in a retrospective study of 92 patients. Moon et al. [6] could not demonstrate any advantage of retrograde cerebral protection over hypothermic circulatory arrest alone in terms of mortality or morbidity in a cohort of 72 patients although the study was possibly too small to definitively exclude a difference. Di Eusianio et al. [7] could not demonstrate a clinical benefit with the use of ACP compared to hypothermic circulatory arrest (HCA) alone when they retrospectively reviewed 289 patients. Hagl et al. [8] demonstrated the benefits of ACP over RCP in terms of transient neurological dysfunction but this did not translate into a significant difference in terms of mortality or permanent neurological dysfunction. Matalanis et al. [9] also failed to illustrate a clinically significant difference between groups. Sinatra et al. [10] identified lack of cerebral protection as an independent risk factor over HCA alone in a cohort study of 85 patients undergoing repair of type A dissection, but could not distinguish an advantage of ACP over RCP.
Table 2 summarises the evidence found in experimental animal studies. Filgueiras et al. [11] demonstrated improved cerebral pH, and high energy phosphate levels during ACP. Duebener et al. [12] found no functional cerebral capillary blood flow on retrograde perfusion of the brains of six pigs. Katz et al. [13] demonstrated that in a rabbit model RCP of the brain does not perfuse the cerebral capillary system. Sakurada et al. [14] demonstrated that ACP improved cerebral evoked potentials, blood flow and metabolism compared to RCP in 19 dogs. Midulla et al. [15] in their porcine model found that less than 5% of blood delivered retrograde via the superior vena cava (SVC) returns via the aortic cannula. Most of the blood went from the SVC via venous collaterals to the inferior vena cava (IVC), despite ligation of the azygous vein. However, behavioural scores in pigs undergoing RCP were better than HCA alone. Hagl et al. [16] demonstrated that cold selective ACP is associated with better neurophysiological recovery and a smaller rise in intracranial pressure in their 12 pig model comparing HCA and selective ACP, they also showed a more prolonged acidosis in the brain tissues of the group who had HCA alone.
Cerebral damage has been hypothesised to be caused by either inadequate cerebral protection or embolic events in these studies. Although physiological cerebral blood flow has not been demonstrated in any of the studies using retrograde perfusion, it is possible that some of the demonstrated clinical benefits of RCP may be due to sustained cerebral cooling or ‘wash out’ of embolic material. ACP has been shown to give physiological flow and improved metabolic effects, however authors report disadvantages including technical complexity, reduced surgical visibility, and manipulation of the aorta and aortic arch vessels, especially in cases of acute dissection or atherosclerotic aortic arch aneurysm.
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7. Clinical bottom line
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ACP is a better strategy than RCP in aortic arch procedures requiring hypothermic circulatory arrest. This is demonstrated in a limited number of prospective randomized controlled clinical studies which have involved small number of patients in cohort studies. The evidence from experimental animal models is more convincing in terms of demonstrating the benefits of ACP.
doi:10.1016/j.icvts.2004.07.008
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References
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- Dunning J, Prendergast B, Kevin Mackway-Jones K. Towards evidence based medicine in cardiothoracic surgery: best BETS Interact Cardiovasc Thorac Surg 2003;2:405-409.[Abstract/Free Full Text]
- Okita Y, Minatoya K, Tagusari O, Ando M, Nagatsuka K, Kitamura S. Prospective comparative study of brain protection in total aortic arch replacement: deep hypothermic circulatory arrest with retrograde cerebral perfusion or selective antegrade cerebral perfusion Ann Thorac Surg 2001;72(1):72-79.[Abstract/Free Full Text]
- Tanoue Y, Tominaga R, Ochiai Y, Fukae K, Morita S, Kawachi Y, Yasui H. Comparative study of retrograde and selective cerebral perfusion with transcranial Doppler Ann Thorac Surg 1999;67(3):672-675.[Abstract/Free Full Text]
- Higami T, Kozawa S, Asada T, Obo H, Gan K, Iwahashi K, Nohara H. Retrograde cerebral perfusion versus selective cerebral perfusion as evaluated by cerebral oxygen saturation during aortic arch reconstruction Ann Thorac Surg 1999;67(4):1091-1096.[Abstract/Free Full Text]
- Moon MR, Sundt III TM. Influence of retrograde cerebral perfusion during aortic arch procedures Ann Thorac Surg 2002;74(2):426-431.[Abstract/Free Full Text]
- Di Eusianio M, Wesselink RMJ, Morshuis WJ, Dossche KM, Schepens MA. Deep hypothermic circulatory arrest and antegrade selective cerebral perfusion during ascending aorta-hemiarch replacement: a retrospective comparative study J Thorac Cardiovasc Surg 2003;125(4):849-854.[Abstract/Free Full Text]
- Hagl C, Ergin MA, Galla JD, Lansman SL, McCullough JN, Spielvogel D, Sfeir P, Bodian CA, Griepp RB. Neurologic outcome after ascending aorta-aortic arch operations: effect of brain protection technique in high-risk patients J Thorac Cardiovasc Surg 2001;121(6):1107-1121.[Abstract/Free Full Text]
- Matalanis G, Hata M, Buxton BF. A retrospective comparative study of deep hypothermic circulatory arrest, retrograde, and antegrade cerebral perfusion in aortic arch surgery J Thorac Cardiovasc Surg 2003;9(3):174-179.
- Sinatra R, Melina G, Pulitani I, Fiorani B, Ruvolo G, Marino B. Emergency operation for acute type A aortic dissection: neurologic complications and early mortality Ann Thorac Surg 2001;71(1):33-38.[Abstract/Free Full Text]
- Neri E, Sassi C, Barabesi L, Massetti M, Pula G, Buklas D, Tassi R, Giomarelli P. Cerebral autoregulation after hypothermic circulatory arrest in operations on the aortic arch Ann Thorac Surg 2004;77:72-80.[Abstract/Free Full Text]
- Filgueiras CL, Winsborrow B, Ye J, Scott J, Aronov A, Kozlowski P, Shabnavard L, Summers R, Saunders JK, Deslauriers R. A 31p-magnetic resonance study of antegrade and retrograde cerebral perfusion during aortic arch surgery in pigs J Thorac Cardiovasc Surg 1995;110(1):55-62.[Abstract/Free Full Text]
- Duebener LF, Hagino I, Schmitt K, Sakamoto T, Stamm C, Zurakowski D, Schafers HJ, Jonas RA. Direct visualization of minimal cerebral capillary flow during retrograde cerebral perfusion: an intravital fluorescence microscopy study in pigs Ann Thorac Surg 2003;75(4):1288-1293.[Abstract/Free Full Text]
- Katz MG, Khazin V, Steinmetz A, Sverdlov M, Rabin A, Chamovitz D, Schachner A, Cohen AJ. Distribution of cerebral flow using retrograde versus antegrade cerebral perfusion Ann Thorac Surg 1999;67(4):1065-1069.[Abstract/Free Full Text]
- Sakurada T, Kazui T, Tanaka H, Komatsu S. Comparative experimental study of cerebral protection during aortic arch reconstruction Ann Thorac Surg 1996;61(5):1348-1354.[Abstract/Free Full Text]
- Midulla PS, Gandsas A, Sadeghi AM, Mezrow CK, Yerlioglu ME, Wang W, Wolfe D, Ergin MA, Griepp RB. Comparison of retrograde cerebral perfusion to antegrade cerebral perfusion and hypothermic circulatory arrest in a chronic porcine model J Card Surg 1994;9(5):560-574.[Medline]
- Hagl C, Khaladj N, Peterss S, Hoeffler K, Winterhalter M, Karck M, Haverich A. Hypothermic circulatory arrest with and without cold selective cerebral perfusion: impact on neurological recovery and tissue metabolism in an acute porcine model Eur J Cardiothorac Surg 2004;26:73-80.[Abstract/Free Full Text]
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Abstract
1. Introduction