Interact CardioVasc Thorac Surg 2008;7:891-897. doi:10.1510/icvts.2008.184184
© 2008 European Association of Cardio-Thoracic Surgery
Best evidence topic - Cardiopulmonary bypass |
Is unilateral antegrade cerebral perfusion equivalent to bilateral cerebral perfusion for patients undergoing aortic arch surgery?
Pietro Giorgio Malvindi,
Giuseppe Scrascia and
Nicola Vitale*
Department of Cardiac Surgery, Policlinico Hospital, University of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
Received 20 May 2008;
received in revised form 30 June 2008;
accepted 3 July 2008
*Corresponding author. Tel.: +39-080-5592392; fax: +39-080-5595087.
E-mail address: nicolavitale7{at}gmail.com (N. Vitale).
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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 unilateral antegrade cerebral perfusion is equivalent to bilateral cerebral plegia for cerebral protection during aortic arch surgery. Altogether 233 papers were found using the reported search, of which 17 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. These papers documented antegrade selective cerebral perfusion in a total of 3548 patients: bilateral cerebral perfusion in 2949 patients and unilateral perfusion in 599 patients. Both methods of cerebral perfusion resulted in neurological injury rates of <5%, but the period of antegrade cerebral perfusion allowed by bilateral perfusion was significantly higher. While unilateral perfusion allowed around 30–50 min, bilateral perfusion allowed 86 to over 164 min of ASCP with an acceptably low CVA rate. Therefore, we conclude that while both methods are acceptable, once the ASCP time is expected to rise over 40–50 min, bilateral cerebral perfusion is the technique that is best documented to be safe.
Key Words: Aortic arch surgery; Cerebral perfusion; Neurologic outcome
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1. Introduction
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A best evidence topic was constructed according to a structured protocol. This is fully described in the ICVTS [1].
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2. Three-part question
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In [patients undergoing aortic arch surgery] does [unilateral or bilateral cerebral perfusion] result in superior [survival and better neurologic outcome].
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3. Clinical scenario
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You are about to operate on a 32-year-old man who has presented as an emergency with a high type A aortic dissection with the tear involving the innominate artery. Several people comment on the fact that he is very tall and thin with long fingers and a high arched palate, and you conclude that it is very likely that he has Marfans. Therefore, you decide to perform a total arch replacement with an elephant trunk into the descending aorta. This is inevitably going to be a long procedure and you are anxious as to whether unilateral cerebral perfusion will be adequate for this young gentleman.
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4. Search strategy
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Medline 1990 to April 2008 using PubMed interface (aortic surgery) and (#1) antegrade cerebral perfusion.
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5. Search outcome
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Using the reported search, 233 papers were identified from which 17 papers provided the best evidence to answer the question. These are summarized in Tables 1 and 2.
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6. Comment
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Dossche et al. [2] reported their experience with thoracic aortic surgery in 106 patients: 37 patients had unilateral and 69 patients bilateral antegrade selective cerebral perfusion (ASCP). They observed an incidence of postoperative transient and permanent cerebral vascular accident (CVA) in 3.8% and 5.4% of patients, respectively. Unfortunately, no information was provided as to which technique of cerebral perfusion resulted in reduced cerebral ischemic events, although the authors concluded that patients undergoing bilateral cerebral perfusion had a reduced rate of in-hospital complications.
Immer et al. [3] compared the hospital and neurologic outcome of 567 patients who underwent aortic arch surgery with different protocols of cerebral protection: 387 patients had deep hypothermic circulatory arrest (DHCA) alone, 91 patients DHCA associated to bilateral antegrade cerebral perfusion, 89 patients had DHCA and unilateral cerebral perfusion from the right axillary artery. The unilateral antegrade perfusion allowed better early survival and it is safer against postoperative permanent CVA (P<0.05). The authors concluded that reducing neck vessels manipulation and the insertion of intraluminal cannulae decreases the thromboembolic events and air embolism.
Olsson et al. [4] compared the hospital outcome and the incidence of postoperative CVA in a series of 65 patients with bilateral ASCP and 17 patients with unilateral ASCP for aortic surgery. The propensity score analysis showed a higher incidence of stroke after unilateral ASCP. Furthermore, the multivariable model showed unilateral ASCP was the only variable independently related to stroke. These clinical findings are supported by anatomic studies investigating variations and acquired diseases of the circle of Willis by MR angiography and post-mortem examination. Merkkolla et al. [5] studied the anatomy of the cerebral arteries of 87 deceased individuals by angiography and permanent silicone casts: 22% of the anterior communicating arteries and 46% of the left posterior communicating arteries were missing, these findings may cause insufficient contra-lateral perfusion. Several series of patients undergoing elective and emergency surgery with unilateral antegrade selective cerebral perfusion document an incidence of postoperative cerebral vascular accident ranging from 0.6% up to 10% [6–11], with transient CVA having a higher incidence than permanent CVA [8, 10]. In all these experiences direct cannulation of epiaortic vessels was avoided, right axillary artery or upper brachial artery were cannulated for CPB establishment and the achievement of unilateral cerebral perfusion. Although all these studies report good results with unilateral antegrade cerebral perfusion, three of them are small series [7, 9, 10]. In the remaining two studies [6, 8, 11], short time of unilateral cerebral perfusion are reported with a mean time of cerebral plegia of 39±22 min in Tasdemir's experience, 36±27 min in Kucuker's one and 25±12 min in Bakhtiary report. Tasdemir's and Kucuker's series include only small numbers of patients presented with acute aortic dissection. In Bakhtiary's experience all the patients presented with a diagnosis of acute aortic dissection. All these three series include few cases of complex aortic arch procedures.
Kazui and coworkers used bilateral cerebral perfusion [12, 17] in two large series of patients operated upon for total arch replacement (27% for acute aortic dissection). In all cases left common carotid artery was selectively cannulated, the right carotid perfusion was achieved by direct cannulation of the innominate artery or from the right axillary artery that was cannulated directly or by a side graft. The axillary approach was used to establish CPB also. The authors reported an incidence of postoperative transient CVA ranging from 4.2% to 4.9% and permanent CVA ranging from 2.4% to 3.8% over different time spans. Mean cerebral perfusion time was approximately 88±30 min higher than in the reported findings with unilateral perfusion [6, 8]. Moreover, they found that length of time of bilateral cerebral perfusion had no significant correlation with hospital mortality and neurological outcome. Similar results were reported in other studies [13–16, 18] with large series of complex surgical procedures that required a longer time of bilateral cerebral perfusion.
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7. Clinical bottom line
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We found 17 papers including 3548 patients undergoing aortic surgery using either unilateral or bilateral cerebral perfusion. These papers documented bilateral cerebral perfusion in 2949 patients and unilateral perfusion in 599 patients. Both methods of cerebral perfusion resulted in neurological injury rates of <5%, but the period of antegrade cerebral perfusion allowed by bilateral perfusion was significantly higher. While unilateral perfusion allowed around 30–50 min, bilateral perfusion allowed 86 to over 164 min of ASCP with an acceptably low CVA rate. Therefore, we conclude that while both methods are acceptable, once the ASCP time is expected to rise over 40–50 min, bilateral cerebral perfusion is the technique that is best documented to be safe.
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References
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Abstract
1. Introduction