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Antegrade cerebral perfusion with a simplified technique:  unilateral versus bilateral perfusion
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery.
2006 (English)In: Annals of Thoracic Surgery, ISSN 0003-4975, Vol. 81, no 3, 868-874 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Selective antegrade cerebral perfusion has been introduced as a strategy of cerebral protection in operations on the aortic arch with hypothermic circulatory arrest. Several techniques of unilateral and bilateral cerebral perfusion have been described with varying results.

METHODS: Patients underwent either unilateral cerebral perfusion with a cannula in the right subclavian artery or bilateral cerebral perfusion, with an additional cannula in the left carotid artery. A simplified Seldinger-type technique for subclavian artery cannulation was employed. Results were analyzed with multivariable logistic regression analysis and propensity score analysis to adjust for nonrandomized treatment assignment.

RESULTS: Of 65 patients, 17 (26%) had unilateral cerebral perfusion. Mortality was 11% (n = 7); 14% (n = 9) had a stroke. In multivariable analysis, unilateral cerebral perfusion was significantly associated with stroke (odds ratio 6.6 [1.2 to 36]). Age more than 70 years was associated with in-hospital death (odds ratio 12 [1.3 to 113]), and concomitant coronary artery bypass graft surgery was associated with adverse outcome (odds ratio 23 [1.8 to 299]). Balancing variables in a propensity score analysis, stroke remained significantly more common with unilateral brain perfusion (29% versus 0%, p = 0.045). Complications associated with subclavian artery cannulation were encountered in 1 patient (1.5%).

CONCLUSIONS: The described cannulation technique is safe and effective. Bilateral cerebral perfusion is easily achieved and is associated with decreased stroke risk, and should be the preferred brain protection strategy.

Place, publisher, year, edition, pages
2006. Vol. 81, no 3, 868-874 p.
National Category
Medical and Health Sciences
URN: urn:nbn:se:uu:diva-94551DOI: 10.1016/j.athoracsur.2005.08.079PubMedID: 16488686OAI: oai:DiVA.org:uu-94551DiVA: diva2:168433
Available from: 2006-05-10 Created: 2006-05-10 Last updated: 2010-11-12Bibliographically approved
In thesis
1. Thoracic Aortic Surgery: Epidemiology, Outcomes, and Prevention of Cerebral Complications
Open this publication in new window or tab >>Thoracic Aortic Surgery: Epidemiology, Outcomes, and Prevention of Cerebral Complications
2006 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The mortality of thoracic aortic diseases (mainly aneurysms and dissections) is high, even with surgical treatment. Epidemiology and long-term outcomes are incompletely investigated. Stroke is a major complication contributing to mortality, morbidity, and possibly to reduced quality of life.

Study I Increasing incidence of thoracic aortic diseases 1987 – 2002 was demonstrated (n=14229). Annual number of operations increased eight-fold. Overall long-time survival was 92%, 77%, and 57% at 1, 5, and 10 years. Risk of operative and long-term mortality was reduced across time.

Study II 2634 patients operated on the proximal thoracic aorta (Swedish Heart Surgery register) were examined. Aortic valve replacement, coronary revascularization, emergency operation, and age were independently associated with surgical death. Long-term mortality was similar for aneurysms and dissections. Operative mortality was reduced (13.7% vs 7.2%) for aneurysms but remained unchanged (22.3% vs 22.4%) for dissections across time.

Study III 65 patients underwent selective antegrade cerebral perfusion (SACP) uni- or bilaterally. Stroke was significantly more common after unilateral SACP (29% vs 8%, p=0.045), confirmed by propensity score-matched analysis. Subclavian artery cannulation with Seldinger-technique entailed vascular complication in one case (1.5%).

Study IV Near-infrared spectroscopy (NIRS) was used to monitor cerebral tissue saturation (rSO2) during SACP in 46 patients. Lower rSO2 were encountered (1) in patients suffering a stroke (2) with unilateral SACP, and (3) in the affected hemisphere of stroke victims. A decrease of rSO2 by 14 – 21% from baseline increased the risk of stroke significantly.

Study V Quality of life (QoL) in 76 survivors of thoracic aortic surgery was examined with the SF-36 health questionnaire. Except for pain, QoL was reduced in all dimensions. QoL was not affected by acuity of operation. Tendencies of lower QoL after descending aortic operations, after major complications, and with persistent dysfunction were non-significant.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2006. 83 p.
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 155
Surgery, Aorta, Thoracic, Aortic aneurysms, Aortic disease, Cardiovascular surgical procedures, Epidemiology, Registries, Treatment outcome, Survival analysis, Cerebral infarction, Near-infrared spectroscopy, Quality of life, Perfusion, Kirurgi
urn:nbn:se:uu:diva-6899 (URN)91-554-6579-X (ISBN)
Public defence
2006-05-31, Robergsalen, Akademiska sjukhuset, Ingång 40, Uppsala, 13:15
Available from: 2006-05-10 Created: 2006-05-10 Last updated: 2011-04-12Bibliographically approved

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