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Early experience of continuous retrograde cerebral perfusion (CRCP)
Thoracic Aorta II struction was designed to minimize the circulatory arrest time. Eleven cases were performed as emergencies because of rupture and acute dissection. Five patients (19.2%) died (three from bleeding from the distal anastomosis, one from postoperative D1C, one from intraoperative dissection). The remaining 21 patients survived neurologically intact. Retrograde cerebral perfusion with pharmacological brain protection is a very simple method to prevent air embolism and thromboembolism during aortic arch aneurysm repair. This allowed us to perform aortic arch replacements in a bloodless field. In spite of extended circulatory arrest time, recovery of consciousness was complete.
24.4 Aortic Arch Anerusym: N e w Modification of Aortic Arch Reconstruction and Selective Cerebral Perfusion T. KAZUI, T. TANAKA, K. MORISHITA and S. KOMATSU, Sapporo, Japan Selective cerebral perfusion has been used as the method for cerebral protection during aortic arch repair in 150 patients with aortic arch aneurysms at our institution. Recently, we modified our technique of aortic arch reconstruction and selective cerebral perfusion (SCP) in order to reduce the neurological complications. Following the institution of SCP into both innominate and left common carotid arteries at 22°C, the distal graft anastomosis and left subclavian artery reconstruction were performed while the descending aorta was left open. The antegrade perfusion with rewarming was started via the fourth limb attached to the main graft instead of the femoral artery. The aortic arch was completely replaced with the graft using three limbs for the arch vessels. During a 1-year period from December 1993 to November 1994, 30 patients were operated on for aortic arch aneurysms using this technique. The etiology of the aneurysms were as follows: true aneurysm (16) and aortic dissection (14), including eight cases of acute dissection. Concomitant procedures included descending graft replacement in 11 patients, composite graft replacement in five, CABG in three, and AVR in one. The hospital mortality rate was 3.3% (1 in 30 patients). There were no neurological complications. This technique is a useful method for the prevention of neurological complications in the treatment of aortic arch aneurysms.
24.5 Early Experience of Continuous Retrograde Cerebral Perfusion (CRCP) A. USUI, T. ABE, M. MURASE, M. TANAKA, E. TAKEUCHI, T. ISHIHARA, M. HOSHINO, Y. OGAWA, A. SEKI, H. OKAMOTO and H. MORIYA, Nagoya, Japan Continuous retrograde cerebral perfusion (CRCP) is a new technique for protecting the brain during aortic arch surgery. CRCP is performed by infusing cold blood through SVC cannulae and clamping the IVC, while the SVC pressure is maintained around 25 mmHg and the nasopharyngeal temper-
CARDIOVASCULAR SURGERY SEPTEMBER 1995
ature is cooled to 20°C. This study reviews our early clinical results, especially the neurological outcome of CRCP. RESULTS: Fifty-three patients (30 men, 23 women; range 35-89 years; mean 61.8 years) underwent aortic arch surgery with CRCP. True aneurysm was diagnosed in 14 cases and aortic dissection in 39 cases. Emergency operations were performed in 34 cases. The proximal aortic arch was replaced in 36 patients, the total aortic arch was replaced in nine and local reconstruction was used in seven. CRCP time was 60 + 23 min (range 22-115 min) and SVC flow rate was 360 + 160 ml/min. Forty-three patients became conscious within the first postoperative day (group A), but 10 did not awake until the second postoperative day (group B). Neurological deficiency remained in six patients, including one case of brain death. Early mortality was 17%. There were no significant differences between groups, except in CRCP time (55 + 22 min, range 22-115 min vs 83 + 17 min, range 54-115 min; P <0.01). Twenty-eight of 29 cases where CRCP was applied within 60 min and 12 of 17 cases with 60-90 min of CRCP awakened early, while 4 of 7 cases with more than 90 min of CRCP were slow to awake. CONCLUSION: CRCP can be performed without clamping and cannulating cervical arteries. It should reduce any chance of cerebral thrombosis. CRCP can extend the duration of safe cerebral circulatory arrest and should be a good technique for protecting the brain.
24.6 Experimental Study of Brain Protection During Retrograde Cerebral Perfusion using Phosphrous-31
Magnetic Resonance Spectroscopy T. SOEDA, T. HADAMA, K. YAMADA, S. YANAL S. MIYAMOTO, H. SAKO, Y. MORI, O. SHIGEMITU and Y. UCHIDA, Oita, Japan We evaluated the metabolic state of the brain during retrograde cerebral perfusion (RCP) compared with normograde cerebral perfusion (NCP) and circulatory arrest (CA) by measuring the concentration of adenosine triphosphate (ATP) and phosphocreatine (PCr), and the intracellular pH (pHi) using in vivo phosphorus-31 magnetic resonance spectroscopy (31-P MRS). Five monkeys were cooled on cardiopulmonary bypass to 15°C nasopharyngeal temperature. These were divided into three groups: normograde cerebral perfusion (NCP group, n = 2), retrograde cerebral perfusion for 60 min (RCP group, n = 2) and hypothermic circulatory arrest for 60 rain (CA group, n = 1). RCP was performed, maintaining an internal jugular venous pressure of 20-25 cmH20. In the NCP group, at a systemic flow rate of 100 ml/kg/min, there was no significant depletion of ATP or PCr, and the phi remained normal throughout the perfusion. In the CA group, severe intracellular acidosis and depletion of high-energy phosphates occurred. In contrast, RCP resulted in intracellular acidosis, but no depletion of ATP. The cerebral pHi became more acidotic during early reperfusion in the CA group, whereas it showed gradual recovery in the RCP group. Recovery of cerebral PCr and pHi during the initial 60 min of reperfusion was faster in RCP group. The final recovery of ATP, PCr, and phi levels were 69.7%, 61.9%, and 6.85, respectively in the CA group, and 98.7%, 112.1%, and 7.21, respectively, in the RCP group. This study indicates that RCP may prolong the safe duration of circulatory arrest.
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24.4 Aortic Arch Anerusym: N e w Modification of Aortic Arch Reconstruction and Selective Cerebral Perfusion T. KAZUI, T. TANAKA, K. MORISHITA and S. KOMATSU, Sapporo, Japan Selective cerebral perfusion has been used as the method for cerebral protection during aortic arch repair in 150 patients with aortic arch aneurysms at our institution. Recently, we modified our technique of aortic arch reconstruction and selective cerebral perfusion (SCP) in order to reduce the neurological complications. Following the institution of SCP into both innominate and left common carotid arteries at 22°C, the distal graft anastomosis and left subclavian artery reconstruction were performed while the descending aorta was left open. The antegrade perfusion with rewarming was started via the fourth limb attached to the main graft instead of the femoral artery. The aortic arch was completely replaced with the graft using three limbs for the arch vessels. During a 1-year period from December 1993 to November 1994, 30 patients were operated on for aortic arch aneurysms using this technique. The etiology of the aneurysms were as follows: true aneurysm (16) and aortic dissection (14), including eight cases of acute dissection. Concomitant procedures included descending graft replacement in 11 patients, composite graft replacement in five, CABG in three, and AVR in one. The hospital mortality rate was 3.3% (1 in 30 patients). There were no neurological complications. This technique is a useful method for the prevention of neurological complications in the treatment of aortic arch aneurysms.
24.5 Early Experience of Continuous Retrograde Cerebral Perfusion (CRCP) A. USUI, T. ABE, M. MURASE, M. TANAKA, E. TAKEUCHI, T. ISHIHARA, M. HOSHINO, Y. OGAWA, A. SEKI, H. OKAMOTO and H. MORIYA, Nagoya, Japan Continuous retrograde cerebral perfusion (CRCP) is a new technique for protecting the brain during aortic arch surgery. CRCP is performed by infusing cold blood through SVC cannulae and clamping the IVC, while the SVC pressure is maintained around 25 mmHg and the nasopharyngeal temper-
CARDIOVASCULAR SURGERY SEPTEMBER 1995
ature is cooled to 20°C. This study reviews our early clinical results, especially the neurological outcome of CRCP. RESULTS: Fifty-three patients (30 men, 23 women; range 35-89 years; mean 61.8 years) underwent aortic arch surgery with CRCP. True aneurysm was diagnosed in 14 cases and aortic dissection in 39 cases. Emergency operations were performed in 34 cases. The proximal aortic arch was replaced in 36 patients, the total aortic arch was replaced in nine and local reconstruction was used in seven. CRCP time was 60 + 23 min (range 22-115 min) and SVC flow rate was 360 + 160 ml/min. Forty-three patients became conscious within the first postoperative day (group A), but 10 did not awake until the second postoperative day (group B). Neurological deficiency remained in six patients, including one case of brain death. Early mortality was 17%. There were no significant differences between groups, except in CRCP time (55 + 22 min, range 22-115 min vs 83 + 17 min, range 54-115 min; P <0.01). Twenty-eight of 29 cases where CRCP was applied within 60 min and 12 of 17 cases with 60-90 min of CRCP awakened early, while 4 of 7 cases with more than 90 min of CRCP were slow to awake. CONCLUSION: CRCP can be performed without clamping and cannulating cervical arteries. It should reduce any chance of cerebral thrombosis. CRCP can extend the duration of safe cerebral circulatory arrest and should be a good technique for protecting the brain.
24.6 Experimental Study of Brain Protection During Retrograde Cerebral Perfusion using Phosphrous-31
Magnetic Resonance Spectroscopy T. SOEDA, T. HADAMA, K. YAMADA, S. YANAL S. MIYAMOTO, H. SAKO, Y. MORI, O. SHIGEMITU and Y. UCHIDA, Oita, Japan We evaluated the metabolic state of the brain during retrograde cerebral perfusion (RCP) compared with normograde cerebral perfusion (NCP) and circulatory arrest (CA) by measuring the concentration of adenosine triphosphate (ATP) and phosphocreatine (PCr), and the intracellular pH (pHi) using in vivo phosphorus-31 magnetic resonance spectroscopy (31-P MRS). Five monkeys were cooled on cardiopulmonary bypass to 15°C nasopharyngeal temperature. These were divided into three groups: normograde cerebral perfusion (NCP group, n = 2), retrograde cerebral perfusion for 60 min (RCP group, n = 2) and hypothermic circulatory arrest for 60 rain (CA group, n = 1). RCP was performed, maintaining an internal jugular venous pressure of 20-25 cmH20. In the NCP group, at a systemic flow rate of 100 ml/kg/min, there was no significant depletion of ATP or PCr, and the phi remained normal throughout the perfusion. In the CA group, severe intracellular acidosis and depletion of high-energy phosphates occurred. In contrast, RCP resulted in intracellular acidosis, but no depletion of ATP. The cerebral pHi became more acidotic during early reperfusion in the CA group, whereas it showed gradual recovery in the RCP group. Recovery of cerebral PCr and pHi during the initial 60 min of reperfusion was faster in RCP group. The final recovery of ATP, PCr, and phi levels were 69.7%, 61.9%, and 6.85, respectively in the CA group, and 98.7%, 112.1%, and 7.21, respectively, in the RCP group. This study indicates that RCP may prolong the safe duration of circulatory arrest.
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