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Published on: September 15, 2023
Extracorporeal Off-Pump Antegrade Cerebral Perfusion in Reconstructive Surgery for Type A Aortic Dissection With
Marina Elias1, Abubakar I Sidik1, Vladimir Mironenko2
1Department of Cardiothoracic Surgery, RUDN University, Moscow, RUS.
Insights
This study introduces an off-pump axillo-axillary shunt for Type A aortic dissection with cerebral malperfusion, offering continuous brain perfusion during surgery. The technique proved safe and effective, minimizing risks associated with traditional cardiopulmonary bypass.
Area of Science:
- Cardiovascular Surgery
- Neurology
- Vascular Surgery
Background:
- Type A aortic dissection (TAAD) frequently causes cerebral malperfusion (CM), leading to neurological damage.
- Traditional cardiopulmonary bypass (CPB) with antegrade cerebral perfusion (ACP) carries risks like embolism and interrupted blood flow.
- Protecting cerebral circulation during aortic arch repair in TAAD patients with CM is critical.
Purpose of the Study:
- To evaluate an innovative off-pump axillo-axillary shunt for continuous cerebral perfusion during TAAD repair with CM.
- To assess the safety and efficacy of this technique compared to traditional CPB methods.
- To reduce neurological complications and operative risks in high-risk TAAD patients.
Main Methods:
- 18 patients with TAAD and CM underwent branch-first stage total aortic arch replacement (BF-TAR) using an axillo-axillary shunt for ACP.
- The shunt provided uninterrupted bihemispheric cerebral perfusion, bypassing traditional CPB.
- Outcomes included operative mortality, neurological complications, CPB times, and overall morbidity.
Main Results:
- The axillo-axillary shunt ensured stable, continuous ACP in all patients, with no new permanent neurological deficits.
- Transient neurological symptoms occurred in 27.8% but resolved within 48 hours.
- Operative mortality was 5.6%, with manageable minor complications; CPB times were significantly reduced compared to literature averages.
Conclusions:
- The off-pump axillo-axillary shunt is a safe and effective technique for maintaining cerebral perfusion during TAAD repair with CM.
- This method mitigates CPB-related risks, improving neurological and surgical outcomes.
- Further research with larger cohorts is recommended to confirm long-term benefits.
Abstract:
Introduction Type A aortic dissection (TAAD) is a life-threatening condition that often leads to cerebral malperfusion (CM), a severe complication that can result in permanent neurological damage. Traditionally, a cardiopulmonary bypass (CPB) with selective antegrade cerebral perfusion (ACP) is employed during aortic arch reconstruction to protect cerebral circulation. However, the use of CPB carries inherent higher risks, including embolic events, hypothermia, and interrupted cerebral perfusion, especially in patients with CM. This study evaluates an innovative off-pump extra-corporeal ACP technique using an axillo-axillary shunt to provide uninterrupted bihemispheric cerebral perfusion during branch-first stage total aortic arch replacement (BF-TAR) for TAAD with CM; the shunt depends on cardiac contradiction to transfuse blood from the donor axillary artery to the recipient axillary artery, which then flows to through the carotid and vertebral arteries to the brain. Methods Between 2021 and 2023, 18 patients with TAAD complicated by CM underwent BF-TAR; the novel axillo-axillary shunt technique was employed for ACP because of the risks of ischemic neurologic injury. Outcomes measured included operative mortality, neurological complications, cardiopulmonary bypass times (measured after completion of the branch-first stage), and overall morbidity. Results The axillo-axillary shunt provided stable, continuous ACP in all patients. No new permanent neurological deficits were observed. Five (27.8%) patients experienced transient neurological symptoms such as blurred vision, dizziness, and confusion, which resolved within 48 hours. Operative mortality was 5.6% (1 patient), and minor complications included transitory lower limbs ischemia in 3 patients (16.7%) and deep sternal wound infection in 1 patient (5.6%). All transitory complications were managed by "watchful waiting". The mean CPB time was 145.3 ± 48.6 minutes, while the mean cross-clamp time was 100.6 ± 17.4 minutes, which was better than the average of 227 ± 32 minutes and 147 ± 23 minutes reported in other studies. Postoperative imaging confirmed well-reconstructed aortic arches with no residual malperfusion or graft-related complications. Conclusion The off-pump axillo-axillary shunt technique provides a safe and effective method for maintaining continuous bihemispheric cerebral perfusion during total aortic arch replacement in patients with TAAD complicated by CM. This approach minimizes the risks associated with CPB, including embolic events and interrupted cerebral perfusion while achieving favorable neurological and surgical outcomes. Further studies with larger cohorts and longer follow-ups are warranted to validate the long-term benefits of this innovative technique.
