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(Circulation. 2004;110:II-231 – II-236.)
© 2004 American Heart Association, Inc.

Surgery for Aortic and Peripheral Vascular Disease

Selective Antegrade Cerebral Perfusion Attenuates Brain Metabolic Deficit in Aortic Arch Surgery

A Prospective Randomized Trial

D.K. Harrington, MB ChB, MRCS; A.S. Walker, MSc RGN; H. Kaukuntla, FRCS; R.M. Bracewell, PhD MRCP; T.H. Clutton-Brock, FRCA MRCP; M. Faroqui, FRCA; D. Pagano, MD FRCS, FESC, FETCS; R.S. Bonser, FRCP FRCS, FESC

From Department of Cardiothoracic Surgery, Queen Elizabeth Hospital, University Hospital Birmingham NHS Trust, Edgbaston, Birmingham, UK.

Correspondence to R. S. Bonser, Department of Cardiothoracic Surgery, Queen Elizabeth Hospital, University Hospital Birmingham NHS Trust, Edgbaston, Birmingham, UK, B15 2TH. E-mail robert.bonser{at}uhb.nhs.uk

Background— Aortic arch surgery has a high incidence of brain injury. This may in part be caused by a cerebral metabolic deficit observed after hypothermic circulatory arrest (HCA). We hypothesized that selective antegrade cerebral perfusion (SACP) would attenuate this phenomenon.

Methods and Results— In a prospective randomized trial, 42 adult patients were allocated to either HCA (22) or SACP. HCA occurred at a nasopharyngeal temperature of 15°C and SACP at a corporeal temperature of 25°C with cerebral perfusion at 15°C. Paired arterial and jugular venous samples were taken before and after arrest. Continuous transcranial Doppler monitoring of middle cerebral artery velocity (MCAV) was performed. Neuropsychometric testing was performed preoperatively and at 6 and 12 weeks postoperatively. There were 3 hospital deaths (7.1%), 2 strokes (4.8%), and 6 episodes of transient neurological deficit (14.3%). From before to after arrest, jugular bulb pO₂ changed by –21.67 mm Hg (26.4) in the HCA group versus +2.27 mm Hg (18.8) in the SACP group (P=0.007). Oxygen extraction changed by +1.7 mL/dL (1.3) in the HCA group versus –1 mL/dL (2.4) in the SACP group (P<0.001). MCAV increased by 6.25 cm/s (9.1) in the HCA group and 19.2 cm/s (10.1) in the SACP group (P=0.001). Incidence of neuropsychometric deficit at 6 weeks was 6/12 (50%) in HCA patients and 8/10 (80%) in SACP patients (P=0.2), and at 12 weeks was 6/16 (38%) in HCA patients and 4/11 (36%) in SACP patients (P=1).

Conclusions— SACP attenuates the metabolic changes seen after HCA. Further studies are required to assess optimal perfusion conditions and clinical outcome.

Key Words: aneurysm • aorta • brain • cerebral ischemia • perfusion