ORGAN PROTECTION

STRATEGIES FOR ANNEURYSM

SURGERIES
Lakshmi Syamkumar
• The last decade has brought many changes in the technique and
practice of perfusion for thoracic aortic surgery.
• The central goal of perfusion is to enable aortic repair while limiting
ischemic injury, especially to the central nervous system.
• Different perfusion strategies are needed to achieve this goal,
depending upon the portion of the aorta that is being treated.
 CPB MANAGEMENT OF ANNEURYSM SURGERIES
• Ascending aneurysm not involving the aortic arch, the management is
same as for coronary revascularisation or valve replacement.
• Moderate to high pump flows, moderate systemic hypothermia and
intermittent cold oxygenated cp are employed.
• Antegrade cp directly in the root or aorta followed by retrograde via
coronary sinus.
 ORGAN PROTECTION STRATEGIES
HYPOTHERMIC CIRCULATORY ARREST,
ANTEGRADE AND RETROGRADE CEREBRAL PERFUSION
• The use of HCA was a major advance in cerebral protection
• HCA also provides a bloodless operative field uncluttered by brachiocephalic
clamps, cannulae, and tourniquets.
• However, some investigators have reported that HCA is neither completely safe
nor satisfactory in reducing cerebral metabolic demands.
• The protective limits of HCA were further defined in 1993 by Svensson et al who
reported Crawford’s experience with 656 patients who underwent HCA during
proximal aortic surgery. The overall rates of transient stroke, permanent stroke,
and early mortality were low, but the incidence of perioperative neurologic
complications rose sharply when the HCA time exceeded 40 minutes, and
mortality increased dramatically when HCA time exceeded 65 minutes.
RETROGRADE CEREBRAL PERFUSION
• retrograde cerebral perfusion (RCP) became popular as a means of safely
extending HCA times.
• It was first described in 1980 by Mills and Ochsner as a method of treating
massive air embolism during CPB.
• However, the concept of using RCP as an adjunct to HCA did not arise until
Ueda et al. introduced RCP for neuroprotection during aortic arch surgery.
• The theoretical benefits of adding RCP to HCA include more homogeneous
cerebral cooling; washout of airbubbles, embolic debris, and metabolic
waste products; prevention of cerebral blood cell microaggregation; and
delivery of oxygen and nutritional substrates to brain tissue
• Despite these potential advantages, experimental and clinical data do
not consistently support the efficacy of RCP for cerebral protection.
• Experimental data increasingly suggested that RCP does not
effectively deliver blood to the brain; rather the benefits of RCP
seemed to be strictly related to maintaining regional hypothermia
and flushing air and debris out of the cerebral circulation.
• Surgery involving the descending thoracic aorta may interrupt blood
flow to the spinal cord via the anterior spinal artery and causes
paraplegia.
• Although drainage of cerebrospinal fluid has long been proposed as a
means of improving spinal cord perfusion, debate continues as to its
efficacy .
• More recently , CSF drainage has been shown to reduce the
incidence of paraplegia by 80% in a randomised study of 145 patients
undergoing thoracoabdominal aneurysm repair.
• An alternative to spinal cord protection is the continuous infusion of
ice cold saline into the epidural space.
DRUGS USED FOR NEUROLOGICAL PROTECTION
• At present no drug is specifically licenced for neuroprotection during
cardiac surgery.
• over the last 4 decades a wide variety of compounds have been evaluated
in the setting of cardiac surgery , which include anesthetic
agents(barbiturates,propofol,volatile agents),ccbs, immune
modulators(corticosteroids,ciclosporin),aminoa acid receptor antagonists
(magnesium,remacimide),glutamate release
inhibitors(lignocaine,phenytoin),antiproteases (aprotonin,nafamostat)and
free radical scavengers(mannitol)
• In many centers thiopental 15-30mg/kg continues to br administered
before DHCA despite any objective evidence of efficacy. The widely held
belief that thiopental reduces neurological injury in conventional cardiac
surgery is not borne out by the evidence,although there is some suggestion
that it reduces overall mortality .
• Fibroptic jugular venous saturation(SjO2) monitoring provides a
continuous measure of global balance between cerebral o2 supply
and demand. The normal range for SjO2 is quoted to be 55-75% but
may be as high as 85% in some normal individuals.SjO2 monitoring
has high specificity but low sensitivity for the detection of cerebral
ischemia.
• SjO2 monitoring has been used to assess the adequacy of cerebral
cooling prior to DHCA. Low SjO2 prior to the onset of DHCA is
associated with adverse neurological outcome
• SjO2 monitoring may also be used to monitor the adequacy of SACP
 SELECTIVE VISCERAL PERFUSION AND
COLD RENAL PERFUSION
• Potential complications of TAAA repair include liver
dysfunction,coagulopathy and bowel ischemia.
• When distal aortic perfusion is discontinued,abdominal viscera
become vulnerable to ischemia.
• Renal protection was earlier achieved by infusing 200-400ml of
cold(4degree Celsius) ringer lactate solution.
• Another solution used nowadays for renal protection is renoplegia
• It is given at a flow of 200 ml/min 200 ml into each renal artery
• And it is repeated every 10-20 minutes delivered at a temperature of
4 degree Celsius.
 LEFT HEART BYPASS
• The rationale for using LHB is to provide distal aortic perfusion while the
aorta is cross-clamped, thereby decreasing the ischemic times of distal
organs, particularly the spinal cord .
• LHB has been shown to improve neurologic outcomes in patients with
traumatic aortic injuries.
• Several studies support using LHB to minimize spinal cord ischemia during
TAAA repair.
• It is achieved by using temporary bypass from the LA to either distal
descending thoracic aorta or femoral artery with closed circuit in line
centrifugal pump.
• Common indication : Type I and type II TAAA repair
• Patients with risk for ischemic complications such as aortic dissections or
previous infra renal aortic replacements.