[Cold retrograde brain perfusion in repair of aortic arch dissection or aneurysm]

We have used hypothermic retrograde brain perfusion (RBP) as a cerebral protection concurrently with hypothermic circulatory arrest (HCA) since September 1994. Till January 2000, 59 patients with ascending and arch aortic aneurysms were operated on (32 emergency cases with acute aortic dissection, 27 elective, including 5 with the chronic dissection). Cardio-pulmonary bypass (CPB) was established, using a common femoral artery and two venous caval cannulae, general hypothermia, aorta cross-clamping, and cold crystalloid intermittent cardioplegia via the coronary orifices. In 10 patients with De Bakey type I dissection, in whom the intimal tear was localised either in the arch or high in the ascending aorta near the orifice of the brachiocephalic trunk, and in 1 patient without dissection, after implementing HCA, continuous RBP was carried on with cold oxygenated blood via the superior caval cannula from its additional connection with the arterial line. After accomplishing the distal anastomosis (in 6 cases with the top of the arch containing the orifices of the brachiocephalic arteries and upper descending thoracic aorta, in 1 case using artificial arch, in 4 cases before the orifice of the brachiocephalic trunk) RBP was finished and CPB re-established. The incompetent aortic valve was repaired by suspension of its commissures and the prosthesis was anastomosed proximally above the coronary orifices. Seven patients died, one (with megaaorta syndrome) during the operation, 2 of myocardial failure on the 2nd postoperative day, and 3 of multiple organ disorder (including stroke with hemiparesis in 2) in the 2nd postoperative week (all but one after regaining consciousness). One patient died suddenly at home six weeks after the operation. Four patients are alive, without any neurological damage.

This simple and economical method effectively protects the brain against ischaemia and emboli, without technically prolonging or complicating the operation.