Background: In 1986 we introduced the technique of antegrade selective perfusion of the brain with cold blood during surgery of the aortic arch.
Methods: Between January 1984 and March 1998, 171 patients (118 males and 53 females) aged 25 to 83 years (mean 56.5 +/- 17), underwent replacement of the transverse aortic arch with the aid of cold blood antegrade selective perfusion. One hundred twenty two patients (71.3%) with chronic lesions were operated on electively; 49 patients (28.6%) were operated on urgently for acute aortic dissection (42 patients) or for a ruptured chronic aneurysm (7 patients). Fifty-one patients (29.8%) had previously undergone a surgical procedure on the thoracic aorta. Mean duration of cardiopulmonary bypass was 121 minutes (range: 65-248); mean duration of cerebral perfusion was 60 minutes (range: 15-90), and mean duration of systemic circulatory arrest circuit was 32 minutes (range: 10-57). The electroencephalogram, routinely recorded, showed disappearance of electrical activity in a mean of 9 minutes (range: 3-16) initial return of electrical activity after a mean of 12 minutes (range: 1-35) and normalization in a mean time of 66 minutes.
Results: All patients but 7 (4%) showed signs of normal awakening within 8 hours postoperatively. Six patients (3.5%) had fatal neurologic complications, and 16 patients (9.3%) had a non-fatal neurologic complications. Twenty-nine patients (16.9%) died during the postoperative hospital course. There was a significant difference between patients aged less than 60 years (9%) and patients older than 60 years (mortality rate 26.4%, p < 0.02). There was also a significant difference between patients undergoing an isolated replacement of the arch, and those in whom the replacement was extended to the descending aorta in whom mortality was 36.4% (chi2, p < 0.02). Lesion and gender had no significant influence on the outcome of the patients, nor had the duration of cardiopulmonary bypass, circulatory arrest, and cerebral perfusion. In particular, no correlation could be established between the duration of cerebral perfusion and the occurrence of neurologic complications.
Conclusion: The clinical results obtained throughout this experience have demonstrated that selective antegrade cerebral perfusion with cold blood provides excellent protection during surgery of the transverse aortic arch. In addition, it avoids the use of deep hypothermia and prolonged cardiopulmonary bypass and does not limit the time allowed to perform the aortic repair. In our opinion it is the technique of choice, especially in frail patients or those requiring a long and difficult procedure.