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Antegrade selective cerebral perfusion in operations on the proximal thoracic aorta
K M Dossche1, M A Schepens, W J Morshuis
1Department of Cardiothoracic Surgery, St. Antonius Ziekenhuis, Nieuwegein, The Netherlands.
Insights
Bilateral antegrade cerebral perfusion significantly reduces hospital mortality in thoracic aorta surgeries. Preoperative instability and technical issues increase neurologic complications, while perfusion duration does not impact outcomes.
Area of Science:
- Cardiovascular Surgery
- Neurology
- Critical Care Medicine
Background:
- Thoracic aorta surgeries involving circulatory arrest and antegrade selective cerebral perfusion are complex procedures.
- Understanding factors influencing patient outcomes, including mortality and neurologic complications, is crucial for improving surgical strategies.
Purpose of the Study:
- To identify key determinants of hospital mortality and neurologic complications following thoracic aorta surgery.
- To evaluate the impact of different antegrade cerebral perfusion techniques on patient outcomes.
Main Methods:
- A retrospective analysis of 106 patients undergoing thoracic aorta surgery between 1989 and 1997.
- Patients received either unilateral or bihemispheric antegrade cerebral perfusion during circulatory arrest.
- Surgical indications included atherosclerotic aneurysms, postdissection aneurysms, and acute type A dissections.
Main Results:
- Hospital mortality was 8.5%. Independent predictors of mortality included rethoracotomy, temporary/permanent neurologic dysfunction, and postoperative dialysis.
- Bilateral antegrade selective cerebral perfusion was associated with a favorable impact on hospital mortality (OR 0.08, p=0.007).
- Preoperative hemodynamic instability and perioperative technical problems significantly predicted temporary and permanent neurologic dysfunction.
Conclusions:
- The choice of antegrade cerebral perfusion technique significantly influences hospital mortality in thoracic aorta surgery.
- Preoperative hemodynamic instability is a critical factor affecting both temporary and permanent postoperative neurologic damage.
- The duration of cerebral perfusion did not demonstrate an influence on postoperative neurologic outcomes.
Background:
To determine the factors that influence hospital death and neurologic complications after surgery on the thoracic aorta using circulatory arrest and antegrade selective cerebral perfusion.
Methods:
From May 1989 through April 1997, 106 patients underwent surgery on the thoracic aorta using circulatory arrest and antegrade selective cerebral perfusion. Mean age was 64.0 +/- 11.5 years. Unilateral antegrade cerebral perfusion was used in 37 patients (35%), bihemispheric antegrade cerebral perfusion in 69 patients (65%). Mean antegrade cerebral perfusion time was 50.5 +/- 20.5 minutes. Indication for surgery was atherosclerotic aneurysm in 60 (56.5%) patients, postdissection aneurysm in 26 (24.4%), acute type A dissection in 16 (15.1%), other in 4 (4.0%).
Results:
Hospital mortality was 8.5% (n = 9; 70% CL: 5.8%-11.2%). Independent predictors of hospital mortality were rethoracotomy (odds ratio 5.7, p = 0.02), postoperative temporary (odds ratio 17.3, p = 0.02) or permanent (odds ratio 7.5, p = 0.03) neurologic dysfunction, postoperative dialysis (odds ratio 9.9, p = 0.008). Bilateral antegrade selective cerebral perfusion had a favorable impact on hospital mortality (odds ratio 0.08, p = 0.007). Temporary neurologic dysfunction occurred in 3.8% of patients (n = 4; 70% CL: 2.0%-5.6%); preoperative hemodynamic instability (odds ratio 14.8, p = 0.05) and perioperative technical problems (odds ratio 22.2, p = 0.033) were independent determinants of temporary neurologic dysfunction. Permanent central neurologic damage occurred in 5.4% of patients (n = 6; 70% CL: 3.2%-7.6%). Preoperative hemodynamic instability (odds ratio 18.9, p = 0.009) and approach through a left thoracotomy (odds ratio 9.4, p = 0.031) were significant predictors of permanent neurologic damage.
Conclusions:
Hospital mortality is affected significantly by the choice of technique used for antegrade cerebral perfusion. The incidence of both temporary and permanent postoperative central neurologic damage is influenced by preoperative hemodynamic instability. Duration of cerebral perfusion had no influence on the postoperative neurologic outcome.