ARTICLE IN PRESS doi:10.1510/icvts.2009.228858
Interactive CardioVascular and Thoracic Surgery 10 (2010) 948–952 www.icvts.org
Institutional report - Vascular thoracic
Neurochemical markers during selective cerebral perfusion via the right brachial artery ¨ zatik*, Sabit Kocabeyoglu, Seref A. Ku ¨ mit Kervan, Mehmet Ali O ¨¸ cu ¨ker, Ahmet Saritas, Garip Altintas, U Soner Yavas, Mustafa Pac ¸ Cardiovascular Surgery Clinic, Tu ¨ rkiye Yu ¨ ksek Ihtisas Education and Research Hospital, 06100 Sihhiye, Ankara, Turkey Received 16 November 2009; received in revised form 16 February 2010; accepted 3 March 2010
Abstract Unilateral selective cerebral perfusion through right brachial artery is one of the cerebral protection methods for aortic arch repair. The purpose of this study is to determine whether cerebral perfusion through contra-lateral hemisphere is adequate or not. Seventeen consecutive patients underwent aortic arch repair using low flow antegrade selective cerebral perfusion (ASCP) through right brachial artery under moderate hypothermia. We measured S100b and neuron-specific enolase (NSE) levels, venous O2 saturation, lactate, and glucose from both left and right jugular vein blood samples before, during and following ASCP and cardiopulmonary bypass. There was no operative mortality or neurological complication in these patients. No significant differences were observed in S100b and NSE levels, venous saturation, glucose and lactate between the blood samples which were gathered from both jugular veins, statistically. This technique, as far as biochemical markers are concerned, seems to provide adequate perfusion for both right and left cerebral hemispheres. 䊚 2010 Published by European Association for Cardio-Thoracic Surgery. All rights reserved. Keywords: Aortic arch; Cerebral protection; Neurological injury
1. Introduction Antegrade selective cerebral perfusion (ASCP) can be performed using several different techniques w1–3x. Our group adopted a selective antegrade cerebral perfusion technique through the right brachial artery, in conjunction with moderate hypothermia. This technique has been routinely used in our clinic since 1996 w4x. Whether cerebral perfusion through the left hemisphere is adequate may be a question for this technique. S-100 proteins and neuron-specific enolase (NSE) have been used to estimate the brain injury after cardiac surgery w5x. We undertook this study in patients undergoing open arch repair using the technique of low flow ASCP through the right brachial artery and we evaluated the brain injury and the laboratory outcomes of S100b and NSE serum levels and venous O2 saturation, lactate, glucose from both left and right jugular vein blood samples during and after ASCP. 2. Materials and methods 2.1. Demographics In this study, between February and May 2007, 17 consecutive patients underwent aortic arch reconstruction using ASCP through the right upper brachial artery for cerebral protection in our clinic. Institutional Ethic Committee *Corresponding author. Tel.: q90 312 3061242; fax: q90 312 3100798. ¨ zatik). E-mail address:
[email protected] (M.A. O 䊚 2010 Published by European Association for Cardio-Thoracic Surgery
approval and informed patient consent was obtained from all patients. Their ages ranged from 40 to 76 years (mean 57"12). There were 12 men and five women. Presenting pathologies were Stanford type A aortic dissection in six (three with acute dissection), aneurysmatic dilatation of ascending aorta and aortic arch in 11. Five patients had undergone previous major cardiovascular operations (all were aortic valve replacements). Three patients underwent operations under urgent conditions. Ascending and partial arch replacement was performed in all 17 patients. Echocardiography was performed to all patients before the surgical procedure. Eleven patients had undergone computerized tomographic examination. 2.2. Patient management Patients were placed in a supine position with the right upper extremity in a slightly )908 abduction with a slight external rotation. Blood pressure was monitored with a left radial arterial line. A 10-cm catheter was placed in the left internal jugular vein to collect blood samples at different time points during the operation and to monitor the central venous pressure. Electrocardiogram, arterial oxygen saturation and rectal temperature were monitored for all patients. The cardiopulmonary bypass (CPB) circuit consisted of a roller pump, a cardiotomy reservoir, an arterial filter and a membrane oxygenator with an integrated heat exchanger. Blood electrolytes, glucose and osmolality were monitored
ARTICLE IN PRESS ¨ zatik et al. / Interactive CardioVascular and Thoracic Surgery 10 (2010) 948–952 M.A. O
Brief Case Report Communication
AVR, aortic valve replacement.
Historical Pages
17 4 11 1 1 17
Nomenclature
Ascendingqpartial aortic arch Modified bentall Supra coronary AVR and supra coronary ReAVR and supra coronary Total
Best Evidence Topic
Number of patients
State-of-the-art
Mann–Whitney U-test was used to compare the nonparametric variables between the two different independent groups. Alterations of non-parametric variables in the course of time for each groups were compared with the
Surgical procedure
Follow-up Paper
2.5. Statistical analysis
Table 1 Operative technique
Negative Results
On each sampling, ;10 ml of blood was gathered from each side. Three ml of these blood samples were used to monitor arterial blood gas and lactate which were measured at 37 8C with a blood gas analyzer. The rest of the sample blood were frozen to –80 8C. After all of the 17 patients’ blood samples were collected using a DRG Diagnostics NSE ELISA kit to determine the blood level of NSE and a BioVendor Human S100b ELISA kit was used to determine the blood levels of S100b. All of the patients’ blood samples were analyzed at the same time.
Proposal for Bailout Procedure
Before initiating the CPB Fifteenth minute of ASCP Five minutes after termination of ASCP Five minutes after termination of CPB
There are many variations of antegrade perfusion techniques. Frist and associates described a technique involving unilateral low-flow brain perfusion by either innominate or left carotid artery w7x. Our group has modified this technique by switching the cannulation site to the right brachial artery. Although the brachial artery is somewhat low in diameter there were no specific complications associated with brachial artery use in this cohort. No difficulties were encountered in any patients in this cohort with respect to achieving the desired arterial flow. However, this issue may be a problem for high body surface area patients during the rewarming phase, in that case the arterial inflow is switched to the ascending graft and the patient is rewarmed with full flow. During our routine clinical practice we have encounte rare problems like temporary numbness of right hand fingers, and very rarely occlusion of arteriotomy repair site which is usually repaired under local anesthesia. Use of this unilateral cerebral perfusion technique raises concerns about the adequacy of perfusion to the contra-
ESCVS Article
1. 2. 3. 4.
4. Discussion
Institutional Report
The amount and timing of both left and right jugular vein blood samples are the same. Blood samples were taken in four different time periods:
There was no operative mortality or neurological complication in this cohort of 17 patients. The mean CPB time was 153"50 min (50–231 min). Mean aortic cross-clamp time was 97"36 min (36–165 min). The mean period of low-flow ASCP through the right upper brachial artery was 26"6 min (16–38 min). There were six Stanford type-A dissections, including four acute cases operated on urgently and one of the acute cases ruptured during the sternotomy and required CPR for a short period of time. Ascending and partial aortic arch replacement was performed in all patients (Table 1). We measured S100b and NSE levels, lactate, pH, venous O2 saturation and glucose from both the left and right jugular vein blood samples before, during and after ASCP. Both right and left jugular sample values were in the normal range before CPB. Maximum levels of S100b and NSE were obtained during ASCP, following ASCP they declined. There were no significant difference between two hemispheres at any time of the surgery and postoperatively with regard to measured variables (Figs. 1–3).
Protocol
2.4. Blood samples
3. Results
Work in Progress Report
Our operative technique has been described in detail previously w6x. A purse string suture was placed on the vena cava superior and the same type of catheter which was used to cannulate the left jugular vein to take blood samples, was then inserted into the vena cava superior and carried cephalad 5–7 cm until it reached the vena cava superior bulb. Also, the left jugular vein catheter was checked for its exact position and if it was in the innominate vein it was pulled back 2–3 cm into the left jugular vein by the anesthesiologist. While taking blood samples from the jugular veins, the innominate vein of the patients were occluded. CPB was instituted at a rate of 2.0–2.2 lyminym2. During ASCP, the flow was decreased to 500–600 mlymin (8–10 mly kgymin) at 28 8C rectal temperature. The innominate, left common carotid and, occasionally, the left subclavian artery were clamped with soft vascular clamps. Cross-clamp on the aorta was released. All arch reconstructions and distal anastomosis were performed with open aortic anastomosis technique, while low-flow perfusion through the brachial artery continued. After terminating the distal repair the flow through the upper brachial artery cannula was increased gradually as the soft clamps on the brachiocephalic vessels were released. Air was removed from the vessels and grafts, which were then filled with blood, and the distal graft was cross-clamped. Normal flow rate was reached through the brachial artery cannula and rewarming was begun in accordance with the time necessary for proximal repair.
New Ideas
2.3. Operative technique
Friedman test. For paired samples for each groups the Wilcoxin signed rank test was used. a-Value was accepted as 0.05. A P-0.05 was considered as significant in all of the tests.
Editorial
and kept within normal ranges; perfusion pressure was maintained at 50–70 mmHg.
949
ARTICLE IN PRESS 950
¨ zatik et al. / Interactive CardioVascular and Thoracic Surgery 10 (2010) 948–952 M.A. O
Fig. 1. Mean values of S100b and NSE from both left and right jugular vein blood samples at different time points. ASCP, antegrade selective cerebral perfusion; CPB, cardiopulmonary bypass; NSE, neuron-specific enolase; sO2, jugular venous oxygen saturation.
Fig. 2. Mean values of lactate and pH from both left and right jugular vein blood samples at different time points. ASCP, antegrade selective cerebral perfusion; CPB, cardiopulmonary bypass; NSE, neuron-specific enolase; sO2, jugular venous oxygen saturation.
Fig. 3. Mean values of sO2 and glucose from both left and right jugular vein blood samples at different time points. ASCP, antegrade selective cerebral perfusion; CPB, cardiopulmonary bypass; NSE, neuron-specific enolase; sO2, jugular venous oxygen saturation.
lateral hemisphere w8x. There are reports about incompleteness of the circle of Willis of about up to 22–46%. However, the absence of one of the constituents of this anatomical circle may not be directly translated into inadequate perfusion of the other hemisphere. The two vertebral arteries and two internal carotid arteries supply the brain, and an extensive anastomosis exists between them. The anterior communicating artery joins the two anterior cerebral arter-
ies to each other; posteriorly the basilar artery divides into the two posterior cerebral arteries, each of which is joined to the internal carotid artery of the same side by the posterior communicating artery. Hypothetically, the absence of one of the three communicating arteries in the circle of Willis should not carry hypoperfusion risk since the blood from the right brachial artery will perfuse the whole brain through the vertebral, basilar, and internal
ARTICLE IN PRESS ¨ zatik et al. / Interactive CardioVascular and Thoracic Surgery 10 (2010) 948–952 M.A. O
ESCVS Article Proposal for Bailout Procedure Negative Results Follow-up Paper State-of-the-art Best Evidence Topic Nomenclature Historical Pages Brief Case Report Communication
w1x Kazui T, Washiyama N, Muhammad BAH, Terada H, Yamashita K, Takinami M. Improved results of atherosclerotic arch aneurysm operations with refined technique. J Thorac Cardiovasc Surg 2000;121:491–499. w2x Hagl C, Ergin MA, Galla JD, Spielvogel D, Lansman S, Squitieri RP, Griepp RB. Neurological outcome after ascending aortayaortic arch operations: effect of brain protection technique in high risk patients. J Thorac Cardiovasc Surg 2001;121:1107–1121. w3x Neri E, Massetti M, Capannini G, Carone E, Tucci E, Diciolla F, Prifti E, Sassi C. Axillary artery cannulation in type A aortic dissection operations. J Thorac Cardiovasc Surg 1999;118:324–332. ¨ zatik MA, Sarıtas¸ A, Tas¸demir O. Arch repair with unilateral w4x Ku ¨¸ cu ¨ker ¸ S, O antegrade cerebral perfusion. Eur J Cardiothorac Surg 2005;27:638– 643. w5x Dimitros G, Berger A, Kowatschev E, Lautenschlager C, Borner A, Lindner A, Schulte-Mattler W, Zerkowski H, Zierz S, Deufel T. Predictive value of S100b and NSE serum levels for adverse neurological outcome after cardiac surgery. J Thorac Cardiovasc Surg 2000;119:138–147. ¨ zatik MA, ¸ w6x Tas¸demir O, Sarıtas¸ A, Ku ¨¸ cu ¨ker ¸ S, O Sener E. Aortic arch repair with right brachial artery perfusion. Ann Thorac Surg 2002;73: 1837–1842. w7x Frist WH, Baldwin JC, Starnes VA, Stinson EB, Oyer PE, Miller DC, Jamieson SW, Mitchell RS, Shumway NE. A reconsideration of cerebral perfusion in aortic arch replacement. Ann Thorac Surg 1986;42:273– 281. w8x Uede T, Shimizu H, Ito T, Kashima I, Hashizume K, Iino Y, Kawada S. Cerebral complications associated with selective perfusion of the arch vessels. Ann Thorac Surg 2000;70:1472–1477. w9x Hoksbergen JM, Legemate DA, Ubbink DT, de Vos HJ, Jacobs NJ. Influence of the collateral function of the circle of Willis on hemispherical perfusion during carotid occlusion as assessed by transcranial colorcoded duplex ultrasonography. Eur J Vasc Endovasc Surg 1999;17:486– 492. w10x Gabella G. Cardiovascular system. In: Williams PL, Bannister LH, Martin BH, editors. Grey’s anatomy. New York: Churchill Livingstone, 1995: 1451–1626. ¨ zatik MA, Ku w11x O ¨¸ cu ¨ker ¸ S, Tu ¨lu ¨ce H, Sarıtas¸ A, ¸ Sener E, Karakas¸ E, Tas¸demir O. Neurocognitive functions after aortic arch repair with right brachial artery perfusion. Ann Thorac Surg 2004;78:591–595. ¨ , Erdemli O ¨, O ¨ zatik MA, Yamak B, Demirci A, Ku w12x Karadeniz U ¨¸ cu ¨ker ¸ S,
Institutional Report
References
Protocol
The authors wish to acknowledge the valuable contributions made by Mustafa Balci in biochemical analysis.
Work in Progress Report
Acknowledgements
New Ideas
to maintain the metabolism of both hemispheres for at least about 30 min (mean ASCP time was 26q6 min for the cohort ranging between 16 and 38 min). A major limitation of this study however, is that none of the 17 patients in the study cohort had neurological complications. Neither had any patient in this cohort had any sign of minor neurological injury. But we did not conduct neuropsychiatric assessment to detect clinically insignificant neurological changes. In our current practice, this simplified right upper brachial artery perfusion technique is the standard for elective and emergent operations of atherosclerotic or degenerative arch aneurysms and dissections. It provides technical simplicity, better surgical exposure with enhanced comfort for the surgeon and less risk of retrograde cerebral embolization. In this small study, no differences in biochemical markers were identified between the right and left sides with use of ASCP via the right brachial artery. This may be indicative of good bilateral perfusion and be related to the subsequent low neurological morbidity. Larger trials are needed to further substantiate the findings.
Editorial
carotid arteries. The only case in which a potential hazard for contra-lateral lobe hypoperfusion exists is the absence of both anterior and left posterior communicating arteries. Hoksbergen and colleagues, in their transcranial duplex study investigating the influence of collateral function of the circle of Willis on 46 cases, mentioned this combination occuring in one patient w9x. However, even in such a case, only the frontal and temporal parts should become affected w10x. In our experience, at the initiation of antegrade perfusion, visual assessment of the returning blood through left common carotid and subclavian arteries has been one of the valuable proofs of contra-lateral hemispheric perfusion, and its amount was always satisfactory. In our previous study, out of 181 patients, four had a major neurological event and one of these was transient. Total and permanent neurological event rates in this series were 2.2% and 1.6%, respectively w4x. In another of our studies, we measured neurocognitive functions of both the right and left hemisphere pre- and postoperatively. For both hemispheric cognitive functions no deterioration was detected w11x. Furthermore, we evaluated that the flow patterns of both the right and left middle cerebral arteries before, during and after low-flow ASCP with transcranial Doppler (TCD) measurements. A reduction of blood flow at the left side was observed after the onset of ASCP. Nevertheless, TCD revealed that the blood flow never stopped and this reduced flow as far as our neurological results was concerned, was satisfactory to maintain the metabolism of the left hemisphere w12x. Neurobiochemical markers of damage to neuronal (NSE) and glial (S100b) brain tissue are significantly associated with the early neuropsychological and neuropsychiatric outcome of cardiac surgery with CPB w6x. S100b may reach its peak values 24 h after the ischemic insult. However, we decided to investigate both hemispheric values intraoperatively. Acutely responding parameters like glucose, lactate, pH, and O2 saturation were in the scope of the study along with NSE and S100b. We thought that best timing for these parameters would be intraoperative sampling. Mixed venous oxygen saturation (SvO2 ) and central venous oxygen saturation (ScvO2 ) have been proposed as indicators of the adequacy of oxygen supply. Jugular venous saturation monitoring reflects a ratio between cerebral blood flow and the cerebral metabolic rate for oxygen w13x. Markedly elevated lactate levels in brain tissue are common after severe head injury. During the early period after severe head injury, lactate levels were increased in brain tissue w14x. Increased as well as decreased arterial blood glucose concentrations contribute to evolving brain damage following traumatic brain injury by inducing neurological deterioration, impairing neurological recovery, and increasing morbidity and mortality w15x. In this study, the measurements of S100b and NSE jugular vein levels revealed that there was no significant difference between right and left jugular vein blood samples, statistically. Previously, we demonstrated that left middle cerebral artery flow was reduced but blood flow never stopped w12x. Despite reduced perfusion to the left hemisphere, no biochemical difference between both hemispheres suggest that oxygen demand of the brain tissue is reduced due to hypothermia, and unilateral perfusion seems to be enough
951
ARTICLE IN PRESS 952
w13x
w14x
w15x
¨ zatik et al. / Interactive CardioVascular and Thoracic Surgery 10 (2010) 948–952 M.A. O Sarıtas¸ A, Tas¸demir O. Assessment of cerebral blood flow with transcranial Doppler in right brachial artery perfusion patients. Ann Thorac Surg 2005;79:139–146. Mattox KL, Moore EE. Jugular venous saturation monitoring and brain tissue oxygen monitoring. In: Feliciano DV, editor. Trauma, 6th edition. New York, NY: McGraw-Hill, 2007:253–284. Menzel M, Doppenberg E, Zauner A, Soukup J, Reinert M, Bullock R. Increased inspired oxygen concentration as a factor in improved brain tissue oxygenation and tissue lactate levels after severe human head injury. J Neurosurg 1999;91:1–10. Meier R, Be ´chir M, Ludwig S, Sommerfeld J, Keel M, Steiger P, Stocker R, Stover JF. Differential influence of arterial blood glucose on cerebral metabolism following severe traumatic brain injury. Crit Care 2009; 13:1–13.
eComment: Re: Neurochemical markers during selective cerebral perfusion via the right brachial artery Authors: Leo A. Bockeria, Bakoulev Center for Cardiovascular Surgery, 121552 Moscow, Russia; Anatoliy I. Malashenkov, Sergey V. Rychin doi:10.1510/icvts.2009.228858A One-stage ascending aorta and arch replacement at the moment represent 14–50% of the general number of the interventions which are carried out on the proximal aorta. Despite gradual improvement of the results in surgery of the aortic arch, brain injury remains the most feared complication and is a frequent cause of death. Available techniques of cerebral protection include deep hypothermic circulatory arrest alone or in combination with retrograde cerebral perfusion and antegrade selective cerebral perfusion.
We have read with great interest the report of this original and inexpensive ¨ zatik and colleagues w1x. However, in our opinion, direct technique by O cannulation of the brachial artery can be difficult in case of a small diameter of the artery. For this purpose, it is probably better to perform a synthetic graft-to-artery anastomosis with graft cannulation, or cannulation of a greater subclavian artery. We have been applying antegrade cerebral perfusion during aortic arch surgery since 1998. Until now we have experience of 66 such operations. Since 2004 the right-sided unilateral selective antegrade cerebral perfusion (SACP) through the right subclavian artery was predominantly used. Despite the messages of some authors that stroke was more common after a strategy of unilateral SACP w2x, we have obtained opposite data. The key point in the successful use of this method is the functioning circle of Willis. In our study, flow velocity in the middle cerebral artery (examined by transcranial Doppler) was demonstrated to be unsignificantly lower in the left cerebral hemisphere with unilateral SACP, and we had no neurologic event. If it is necessary, bilateral SACP can be easily achieved by inserting a cannula in the left carotid artery orifice under direct vision. In our opinion, it is an effective, simple and inexpensive technique. References ¨ zatik MA, Kocabeyoglu S, Ku w1x O ¨cu ¨ker SA, Saritas A, Altintas G, Kervan U, Yavas S, Pac M. Neurochemical markers during selective cerebral perfusion via the right brachial artery. Interact CardioVasc Thorac Surg 2010;10:948–952. w2x Olsson C, Thelin S. Antegrade cerebral perfusion with a simplified technique: unilateral versus bilateral perfusion. Ann Thorac Surg 2006; 81:868–874.
