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• W2894979189 abstract "Hypothermic circulatory arrest and selective cerebral perfusion are standard procedures during total arch replacement to treat acute type A aortic dissection. However, organ ischemia during anastomosis between the graft and descending aorta contribute to high risk of mortality and morbidity. Here we describe the combination of antegrade cerebral perfusion and retrograde inferior vena caval perfusion as a way to ensure continual perfusion of the brain, abdominal viscera, and spinal cord during anastomosis and thereby improve outcomes of total arch replacement. Hypothermic circulatory arrest and selective cerebral perfusion are standard procedures during total arch replacement to treat acute type A aortic dissection. However, organ ischemia during anastomosis between the graft and descending aorta contribute to high risk of mortality and morbidity. Here we describe the combination of antegrade cerebral perfusion and retrograde inferior vena caval perfusion as a way to ensure continual perfusion of the brain, abdominal viscera, and spinal cord during anastomosis and thereby improve outcomes of total arch replacement. The Video can be viewed in the online version of this article [https://doi.org/10.1016/j.athoracsur.2018.08.013] on http://www.annalsthoracicsurgery.org. The Video can be viewed in the online version of this article [https://doi.org/10.1016/j.athoracsur.2018.08.013] on http://www.annalsthoracicsurgery.org. A standard treatment for acute type A aortic dissection is the combination of total arch replacement and elephant trunk implantation, which are carried out with the aid of deep hypothermic circulatory arrest and selective cerebral perfusion. Total arch replacement is associated with substantial morbidity and mortality [1Perreas K. Samanidis G. Thanopoulos A. et al.Antegrade or retrograde cerebral perfusion in ascending aorta and hemiarch surgery? A propensity-matched analysis.Ann Thorac Surg. 2016; 101: 146-152Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar, 2Keeling W.B. Leshnower B.G. Hunting J.C. Binongo J. Chen E.P. Hypothermia and selective antegrade cerebral perfusion is safe for arch repair in type A dissection.Ann Thorac Surg. 2017; 104: 767-772Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar], which may be due to lack of perfusion of the abdominal viscera and spinal cord, low body temperature, and prolonged cardiopulmonary bypass. To reduce these risk factors during repair of the descending thoracic aorta, we have developed a circulatory support technique in which antegrade cerebral perfusion is combined with retrograde inferior vena caval perfusion during maintenance of moderate body temperature. Between 29 October 2017 and 30 November 2017, total arch replacement involving the combination of antegrade cerebral perfusion and retrograde inferior vena caval perfusion was performed in 6 patients (all were men; age 46 ± 11 years). After induction of anesthesia, we routinely monitored blood pressure in the bilateral radial arteries and a femoral artery, bilateral regional cerebral oxygen saturation (rSO2) by transcutaneous oximetry (EGOS-600A, Suzhou Engine Bio-medical Electronics, Suzhou, China), and nasopharyngeal and rectal temperature. A cardiopulmonary bypass circuit was set up involving 2 rolling pumps, membrane oxygenator, and heat exchanger (Fig 1A ). The arterial line was bifurcated after pump 1 and the oxygenator. One branch of the arterial line was designed for systemic perfusion to allow antegrade cerebral perfusion during circulatory arrest. The other branch was connected to pump 2, a pressure monitor, and a drainage tube from the inferior vena cava to allow retrograde inferior vena cava perfusion during circulatory arrest. After sternotomy and systemic heparinization, a cannula was placed in the femoral artery or aorta for systemic perfusion, and 2 cannulae were inserted separately into the superior vena cava and inferior vena cava for systemic venous return. After initiation of total cardiopulmonary bypass, the patient was cooled slowly to induce moderate hypothermia (nasopharyngeal temperature, 28°C to 29°C; rectal temperature, 29°C to 30°C). The aorta was opened, systemic perfusion was stopped, and the combination of antegrade cerebral perfusion and retrograde inferior vena caval perfusion was performed (Fig 1B, Video). Antegrade cerebral perfusion was achieved using a 12 F cannula inserted into the brachiocephalic artery or right axillary artery. The antegrade perfusion flow rate was maintained at 6 to 12 mL • min-1 • kg-1 to keep rSO2 within ±10% of baseline. Retrograde inferior vena caval perfusion was achieved by tethering the inferior vena cava with a band around the cannula and by clamping the distal end of the inferior vena cava drainage tube, allowing pump 2 to drive oxygenated blood into the inferior vena cava. Pump pressure was maintained at 20 to 30 mm Hg, and blood flow was maintained at 8 to 12 mL • min-1 • kg-1. Blood flow in liver and kidney was observed using transesophageal echocardiography (Fig 2, Video). Effluent blood from the lower body returning to the aorta was collected using a flexible sucker and returned to the reservoir in order to maintain a bloodless operative field for anastomoses (Fig 3, Video). After end-to-end anastomoses between the graft and descending aorta, the flexible sucker was removed and the graft was de-aired. Then retrograde inferior vena caval perfusion was stopped, and antegrade perfusion of the lower body was started through the fourth side branch of the graft. Finally, the brachiocephalic artery, left common carotid artery and left subclavian artery were anastomosed with each branch of the graft. Among all 6 patients, retrograde inferior vena caval perfusion lasted an average of 28 ± 6 minutes (range, 21 to 36 minutes) with flow rate of 8.6 ± 1.5 mL/kg and flow pressure of 21 ± 3 mm Hg. Intubation lasted an average of 13 ± 4 hours. Their liver and kidney functions were mildly impaired after surgery, with aspartate transaminase level of 76 ± 30 U/L, alanine aminotransferase level of 79 ± 36 U/L, urea nitrogen level of 9.09 ± 3.13 mmol/L, and creatine level of 108 ± 40 μmol/L. All patients recovered uneventfully and were discharged an average of 10 ± 2 (range, 8 to 13) days after surgery. Satisfactory outcomes when treating acute type A aortic dissection require maintaining blood flow to the brain and visceral organs, as well as creating a bloodless operative field during anastomoses of the graft. To accomplish both objectives, we have developed an approach that combines continuous antegrade cerebral perfusion and retrograde inferior vena caval perfusion during moderately hypothermic circulatory arrest. Two pumps are used to allow precise control of blood flow separately to the brain and lower body. In some ways, our approach is similar to the total body retrograde perfusion reported by Yasuura and colleagues [3Yasuura K. Takagi Y. Oohara Y. Takami Y. Total body retrograde perfusion during operations on the descending thoracic aorta.J Thorac Cardiovasc Surg. 1999; 118: 559-561Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar]. Our approach may be superior, however, because it allows precise control of perfusion flow and pressure in the brain, reducing the risk of excessive or insufficient perfusion. Our method relies on antegrade perfusion, which may be associated with lower risk of transient brain dysfunction than retrograde perfusion [1Perreas K. Samanidis G. Thanopoulos A. et al.Antegrade or retrograde cerebral perfusion in ascending aorta and hemiarch surgery? A propensity-matched analysis.Ann Thorac Surg. 2016; 101: 146-152Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar, 4Okita 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: 72-79Abstract Full Text Full Text PDF PubMed Scopus (203) Google Scholar]. Retrograde inferior vena caval perfusion may provide blood flow to visceral organs and spinal cord during graft anastomosis because of the lack of vein valves in the graft. During this perfusion in all 6 patients in our preliminary study, deoxygenated blood flowed continuously from the opening descending aorta, and no patient suffered injuries to the visceral organs or spinal cord. These results suggest that retrograde inferior vena caval perfusion at a pressure of 20 to 30 mm Hg and flow rate of 8 to 12 mL • min-1 • kg-1 can provide adequate oxygenation to key organs at 29°C. Because we intended to maintain blood flow to vital organs during anastomosis, we chose to induce moderate rather than deep hypothermia in our patients. Using “warmer” temperatures can reduce the duration of cardiopulmonary bypass and perturbation of coagulative function, thus promoting postoperative recovery. Although this preliminary study suggests that our approach holds promise in aortic arch surgery, its safety and efficacy should be tested in a randomized controlled study. Future work should address 1 drawback of the technique, which is that blood returning from the aorta can blur the surgical field. This problem may be solved using flexible suction at the descending aorta. This study was supported by the National Natural Science Foundation of China (81600394 and 81570374) and 1.3.5 project for disciplines of excellence (ZY2016101), West China Hospital, Sichuan University. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiIxZjBmODljMjVjYThkNDMwZmQ4MWU5OWU1ZjExNDJjNyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4NzUzMjc0fQ.mWNCyqbIJuPm_OgPXLlGB3nTrnrBoecgQ6G1CM1Pc0h-v0QYuVv7xevXvkLU2L-r_BUlU47PsIhhhA76uBAJSq6D-YbuSpxGms1IOS9fsDwWM7yla5tSkd6-T0BflZgloMOZ0yPMZVsquJ3EkcLtkCFEduvevoKy4rhLe3GZRtNFGKu1xXfXhAq5qd6VKIeNDboFUXCuGhWgPBI9KHGxuJHGr0H8HQdWRWj9EjYjiIPGE0sDb75BbgmEdKtrDwrMErYDYh3ylwfP8cgZXJAC8tt5kcTKmBIyRNoMIm7C5WK8xyxiqwUjktWXE-sxPwvYDBfclYIvdonJY8Q97-zYnw Download .mp4 (58.97 MB) Help with .mp4 files Video" @default.
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• W2894979189 date "2019-01-01" @default.
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• W2894979189 title "Combining Cerebral Perfusion With Retrograde Inferior Vena Caval Perfusion for Aortic Arch Surgery" @default.
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