We showed, with use of fluorescein retinal angiography, that during retrograde cerebral perfusion, fluorescein injected into the superior vena cava entered the retinal venules, flowed to the capillaries, and subsequently, to. Learn about isolated cerebral perfusion and pros and cons of antegrade or retrograde. We hypothesized that selective antegrade cerebral perfusion sacp would attenuate this phenomenon. As reported in an animal model in 2005, intermittent pressureaugmentedrcp iparcp provides more effective cerebral perfusion than rcp. A novel approach andrea venturini, md, phd1 alan gallingani, md1 angiolino asta, md1 chiara zanchettin, md1 giampaolo zoffoli, md1 antonio cannarella, md1 domenico mangino, md1 1department of cardiac surgery, ospedale dellangelo, mestre. The present study was designed to investi gate flow distribution to the brain during retrograde cerebral perfusion with india ink as a marker. Although 10 years ago the vast majority of surgeons tended to use rcp, nowadays only 15%20% of them continue to practice. Retrograde cerebral perfusion via the superior vena cava during deep hypothermic circulatory arrest has evolved as a means of cerebral protection in aorticarch surgery. Comparison between antegrade and retrograde cerebral perfusion or profound hypothermia as brain protection strategies during repair of type a aortic dissection sotiris c. It may be performed during surgery that interrupts the normal arterial supply of blood to that organ.
Impact of retrograde cerebral perfusion on ascending. Retrograde cerebral perfusion is initiated through the superior vena cava cannula using a centrifugal pump. The optimal brain protection strategy for prolonged periods of circulatory arrest is still controversial. Conventional retrograde cerebral perfusion rcp with 15 mmhg of superior vena cava pressure was performed first, and 30 min later, when the anesthesiologist alert that nearinfrared oximetry showed a low value under 50%, we converted to the intermittent pressure augmented retrograde cerebral perfusion iparcp. Antegrade cerebral perfusion acp with endtoside axillary artery anastomosis with gelweave graft. Protection of the brain by retrograde cerebral perfusion during.
Oxygen delivery during retrograde cerebral perfusion in. Retrograde cerebral perfusion is used as an adjunct to deep hypothermic circulatory arrest dhca for cerebral protection while dealing with complex aortic lesions. Antegrade cerebral perfusion and retrograde inferior vena. This is a brief presentation on antegrade and retrograde cerebral perfusion techniques. Repair of the transverse arch using retrograde cerebral perfusion during acute type a aortic dissection 5.
Retrograde cerebral perfusion rcp has proven to be a safe and effective alternative in providing cerebral protection past the safe period while maintaining a simple, nonencumbered surgical field. Perfweb 22 antegrade and retrograde selective cerebral. Selective antegrade cerebral perfusion attenuates brain. Prospective comparative study of brain protection in total aortic arch replacement deep hypothermic circulatory arrest with retrograde cerebral perfusion or selective antegrade cerebral perfusion. Antegrade selective cerebral perfusion ascp, as demonstrated by various authors, is the best method of brain protection during aortic arch surgery. The choice of cerebral perfusion strategy for aortic arch surgery has been debated, and the superiority of antegrade acp or retrograde rcp cerebral perfusion has not been shown. Figure 2 continuous retrograde cerebral perfusion circuit. Selection of a brain protection method is a primary concern for aortic arch surgery. Retrograde cerebral perfusion provides negligible flow through. Lsfg can also measure the mean blur rate, which quantitatively calculates the blood flow.
Serial measurements of o 2 extraction ratio oer, pco 2, and ph from the rcp inflow and outflow were used to determine the time course for o 2 delivery in 28 adults undergoing aortic reconstruction using hca with rcp. Bayesian estimation of cerebral perfusion using a physiological model of microvasculature kim mouridsen,a. The most common perfusion methods have been antegrade acp andor retrograde rcp cerebral perfusion, both popularized in the early 1990s. Optimal perfusion pressure for experimental retrograde. Even though antegrade cerebral perfusion acp is more widely used than retrograde cerebral perfusion rcp, the difference in benefit and risk between acp and rcp during dhca is uncertain. Backgroundretrograde cerebral perfusion rcp during profound hypothermic circulatory arrest has been used as an adjunct for cerebral protection for repairs of the ascending and transverse aortic arch. Retrograde cerebral perfusion rcp is a technique to improve the safety of dhca by providing partial perfusion to the brain using the cardiopulmonary bypass circuit during interruption of antegrade cerebral perfusion. However, organ ischemia during anastomosis between the graft and descending aorta contribute to high risk of mortality and morbidity. We showed, with use of fluorescein retinal angiography, that during retrograde cerebral perfusion, fluorescein injected into the superior vena. Retrograde cerebral perfusion for brain protection in aortic. This study evaluated whether retrograde cerebral perfusion rcp provides adequate brain protection for prolonged periods of deep hypothermic circulatory arrest dhca. Here we describe the combination of antegrade cerebral perfusion and retrograde inferior vena caval. Retrograde perfusion retroperfusion is an artificial method of providing blood supply to an organ by delivering oxygenated blood through the veins. Maldistribution of the cerebral blood flow in retrograde.
More recently, innominate artery cannulation has been shown to be a. Retrograde cerebral perfusion in human brains the lancet. Cerebral mal perfusion figure 2 although any organ mal perfusion can have devastating implications, this article will focus speci. Brain protection during aortic arch surgery by perfusing cold oxygenated blood into the superior vena cava was first reported by lemole et al. Retrograde perfusion of arterial blood into the superior vena cava svc during systemic arrest was used in 87%. Cardiac surgery repair of the transverse arch using. Duration of rcp in this setting is not established but.
The beneficial effects of rcp may be its ability to sustain brain hypothermia during hypothermic circulatory arrest hca and removal of embolic. In univariate analysis of risk factors for stroke, the stroke rate was 2. Modified circuit for retrograde cerebral perfusion. Antegrade and retrograde cerebral blood flow were calculated by quantitating fluorescent microspheres trapped in brain tissue after the animals were put to death. Results neurologic dysfunction was reported in 6% of patients. Repair of the transverse arch using retrograde cerebral. The evidence in support of emergent retrograde cerebral perfusion combined with postoperative hyperbaric oxygen is limited to case reports and small series w4x. However, the efficacy of retrograde cerebral perfusion to prevent embolic events in aortic arch surgery is well established w6x. We evaluated cerebral metabolism during retrograde cerebral perfusion rcp and circulatory arrest during profound hypothermia, and also investigated the effects of perfusion pressure on rcp. Pdf antegrade versus retrograde cerebral perfusion for. The most common perfusion methods have been antegrade acp andor retrograde rcp cerebral perfusion, both popularized in the. If cerebral mal perfusion is observed, then operative maneuvers are.
We initiate rcp of 500 mlmin and increase this pressure until reversal of middle cerebral artery blood flow is identified. What is the safe limit for retrograde cerebral perfusion with hypothermic circulatory arrest in aortic surgery. Retrograde cerebral perfusion is commonly used as an adjunct to hypothermic circulatory arrest to enhance cerebral protection during thoracic aortic surgery. Lobdell3, kamal khabbaz4, edward murphy5, robert c. Systemic hypothermia along with antegrade cerebral perfusion acp is the accepted cerebral protection approach, with axillary artery cannulation being the most common technique used to establish acp. Comparison between antegrade and retrograde cerebral. But what about deep regional hypothermia of brain for cardiac arrest. Retrograde cerebral perfusion through the superior vena cava svc has been proposed to protect the brain from ischaemic injury during profound hypothermic circulatory arrest phca. Simple retrograde cerebral perfusion is as good as complex antegrade cerebral perfusion for hemiarch replacement cerebral complication is a major concern after aortic arch surgery, which may lead to death. Drs me debakey, es crawford, da cooley and gc morris first reported successful resection and repair of a fusiform aneurysm of the aortic arch with replacement graft in 1957. We aimed to assess the utility of lsfg in the evaluation of cerebral perfusion during aortic surgery under hypothermic circulatory arrest with retrograde and antegrade cerebral perfusion. Observations of retinal vessels during intermittent. This cannula will be used for retrograde cerebral perfusion rcp during circulatory arrest. Background aortic arch surgery has a high incidence of brain injury.
In order to minimize this cerebral risk during dhca, perfusion adjuncts such as antegrade cerebral perfusion acp and retrograde cerebral perfusion rcp were introduced into clinical practice 5. The superior vena cava svc is dissected, encircled with an umbilical tape, cannulated with a rightangle cannula, and yconnector is attached to the venous line. Retrograde false channel perfusion a complication of cardiopulmonary bypass during repair of dissecting aneurysms tgeorge pappas, m. Results of aortic arch repair with hypothermic circulatory. We examined the early and late outcomes for acp versus rcp in proximal. This is an advantage in that it reduces the chances of arterial injury or cerebral thrombosis, while not obscuring the operative field.
Retrograde cerebral perfusion as a method of neuroprotection. Observations of retinal vessels during intermittent pressure. Oct 14, 2000 retrograde cerebral perfusion via the superior vena cava during deep hypothermic circulatory arrest has evolved as a means of cerebral protection in aorticarch surgery. Antegrade selective cerebral perfusion in thoracic aorta. Different strategies are currently in use depending on each individual surgeons experience.
Cardiovascular surgical repair of arch aneurysms is taking a step forward by going backwards by utilizing retrograde cerebral perfusion. Pump pressure of retrograde perfusion was is maintained at 2030 mmhg, and blood flow was is maintained at 8. Antegrade and retrograde selective cerebral perfusion. Brain freeze selective retrograde cerebral perfusion. In this study antegrade and retrograde cerebral perfusion were performed in pigs during circulatory arrest under deep hypothermic conditions 15 c. Antegrade versus retrograde cerebral perfusion for hemiarch. Retrograde cerebral perfusion as an adjunct to prolonged. In aortic arch surgery, deep hypothermic circulatory arrest dhca combined with cerebral perfusion is employed worldwide as a routine practice. Retrograde cerebral perfusion can extend the duration of safe cerebral circulatory arrest. Retrograde cerebral perfusion may reduce ischemic damage during interruption of cerebral blood flow. Retrograde cerebral perfusion can be performed without clamping or cannulation of the cervical arteries. We performed a retrospective study to compare the respective advantages and disadvantages of retrograde cerebral perfusion rcp and selective cerebral perfusion scp in patients who underwent surgery for acute type a aortic dissection.
Between january 1991 and march 1995, 161 patients were operated on for aneurysms of the ascending aorta and transverse arch. Total aortic arch replacement under intermittent pressure. The clinical application of continuous retrograde cerebral perfusion rcp with hca for aortic arch surgery was first shown by ueda and. Unilateral selective antegrade cerebral perfusion may produce contralateral cerebral hypoperfusion and ischemia if collateral blood flow via the circle of willis is compromised. Cerebral protection with retrograde cerebral perfusion. Introduction neurological injury remains the major cause of morbidity and mortality following open aortic arch repair. Figure 2 from a reappraisal of retrograde cerebral perfusion. Selective antegrade cerebral perfusion sacp via the innominate and left common carotid arteries has long been used as an adjunctive cerebral protective technique. A reappraisal of retrograde cerebral perfusion ncbi. Retrograde cerebral perfusion has been applied recently in aortic surgery to protect.
Methods and results in a prospective randomized trial, 42 adult patients were allocated to either hca 22 or sacp. In patients with aortic dissection, cerebral malperfusion can. The methodologies of hypothermic circulatory arrest and of. After measuring the cerebral blood flow distribution in acp,the perfusion was then switched to rcp through the bilateral internalmaxillary vein and the svc pressure was kept at 40 mmhg. Rcp is carried out through a superior vena cava cannula. Hypothermic circulatory arrest and selective cerebral perfusion are standard procedures during total arch replacement to treat acute type a aortic dissection. Hca occurred at a nasopharyngeal temperature of 15c and sacp at a corporeal temperature of 25c with cerebral perfusion at. Retrograde cerebral perfusion provides negligible flow. While deep hypothermic circulatory arrest alone remains a viable approach in many instances, the need for prolonged duration of circulatory arrest and increasing case. Adult cardiac surgery database training manual, v2. It was not until 1986 that ueda and associates6 developed a clinically feasible method for the application of rcp to be used concurrently with dhca to improve cerebral pro. In a study evaluating profound hypothermic circulatory arrest during transverse aortic arch repair, the incidence of tnd was directly related to the duration of cerebral ischemia.
Retrograde cerebral perfusion for aortic arch operation. Although acp may provide superior cerebral perfusion, it requires manipulation of the head vessels, which increases the risk of emboli. Repair of type a aortic intramural hematoma with ascending. Surgical repair of the ascending aorta for aneurysmal disease or dissection is facilitated by using the arrest remaindistal anastomosis technique and deep hypothermic circulatory arrest dhca. Antegrade cerebral blood flow cbf, calculated by means of fluorescent microspheres, at baseline and at 20c deep brain temperature in the groups before 30 minutes of standard retrograde cerebral perfusion rcp and retrograde perfusion with occlusion of the inferior vena cava rcpo. Optimal cerebral protection strategies in aortic surgery. From 1cardiothoracic surgeryclinic, university hospital of. The combination of selective antegrade cerebral perfusion and retrograde inferior vena caval perfusion is performed. If a longer circ arrest period is expected, unilateral antegrade cerebral perfusion acp is a technique that maintains brain perfusion and relies on collateralization through the circle of willis to perfuse the contralateral left brain. Cerebral protection strategies in aortic surgery have undergone significant evolution over the years, but its tenets remain rooted in maintenance of hypothermia and cerebral perfusion to limit adverse neurologic outcomes. Evaluation of cerebral circulation during retrograde. Retrograde cerebral perfusion rcp has been used as a cerebroprotective method under hypothermic circulatory arrest hca during aortic surgery. Combining cerebral perfusion with retrograde inferior vena. Figure 4 bilateral antegrade cerebral perfusion obtained by selective cannulation of the innominate and left common carotid artery.
This new protocol was clinically applied to a 51 yearoldmale with a diagnosis of acute aortic dissection. The effect of retrograde cerebral perfusion on the incidence of stroke and death among patients undergoing repair of aneurysms of the ascending aorta and transverse arch was determined. A reappraisal of retrograde cerebral perfusion ueda. In 1990 ueda and associates first described the routine use of continuous retrograde cerebral perfusion rcp in thoracic aortic surgery for the purpose of cerebral protection during the interval of obligatory interruption of anterograde cerebral flow. Jugular venous pressure and rcp pressure are monitored separately. Deep hypothermia with retrograde cerebral perfusion versus. A 31pmagnetic antegrade and retrograde cerebral perfusion. Deep hypothermic retrograde cerebral perfusion rcp has recently been the focus of interest as a simple new technique of brain protection during the operation for thoracic aneurysms. This may in part be caused by a cerebral metabolic deficit observed after hypothermic circulatory arrest hca. Performing antegrade selective cerebral perfusion using. Rcp, retrograde cerebral perfusion a reappraisal of retrograde cerebral perfusion.
Comparative clinical study between retrograde cerebral. The antegrade perfusion flow rate was is maintained at 612 mlminkg. To prolong the safe limits of conventional retrograde cerebral perfusion rcp, kitahori, kawata, takamoto et al. Two patients underwent total arch replacement for aneurysm. We examined the early and late outcomes for acp versus rcp in. Zack interviewed rob schultz, a ct surgeon resident from calgary who is doing research on deep hypothermia of the brain using some of the tactics that are utilized in operating room. Retrograde cerebral perfusion rcp potentially delivers metabolic substrate to the brain during surgery using hypothermic circulatory arrest hca. Continuous rcp can be started via the bypass connecting arterial and venous tubings by releasing the clamps on the bypass and clamping the inferior vena caval cannula. Pdf retrograde cerebral perfusion and subclavian artery. Retrograde cerebral perfusion via the superior vena cava during deep hypothermic circulatory arrest has evolved as a means of cerebral. Simple retrograde cerebral perfusion is as good as complex. This study was designed to evaluate the use of retrograde cerebral perfusion rcp combined with deep hypothermic circulatory arrest dhca in the treatment of complex congenital and adult cardiac disease. Retrograde cerebral perfusion through a superior vena caval.
Similar cerebral protective effectiveness of antegrade and. Okita and colleagues 3 x 3 okita, y, minatoya, k, tagusari, o, ando, m, nagatsuka, k, and kitamura, s. Retrograde cerebral perfusion is effective for prolonged. Performing antegrade selective cerebral perfusion using the av cannula. Material and methods all animals received humane care in compliance with the.
This suggests cerebral malperfusion and suboptimal cerebral protection. Forty patients were subjected to surgical correction of ascending aorta lesions, 10 were operated for ascending aorta and arch lesions, eight had distal arch aneurysm repair and eight had surgery for thoracoabdominal aortic aneurysms. Some of us have heard of deep hypothermia for traumatic arrest. Repair of aortic arch pathology is reliably performed with hypothermic circulatory arrest, but the best method of brain protection is controversial.
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