Selective Antegrade Cerebral Perfusion Via Right Axillary Artery Cannulation Reduces Morbidity and Mortality after Proximal Aortic Surgery
Michael E. Halkos, Faraz Kerendi, Richard Myung, Patrick D. Kilgo, John D. Puskas, Edward P. Chen; Emory University, Atlanta, GA
Comment on this Abstract
Objective: Selective antegrade cerebral perfusion (SCP) utilizing axillary artery cannulation is a well-described neuroprotective technique during hypothermic circulatory arrest (HCA) in proximal aortic surgery (Ao). This study investigated whether SCP was associated with improved survival and neurologic outcome in both emergent (EM) and elective (EL) settings.
Methods: A single institution retrospective review was performed for all cases of Ao involving HCA between January 2004 and May 2007. Of these 272 patients, 106 presented EM with acute dissection or hematoma, and 166 patients underwent EL operation for other ascending aortic pathology. Patients were classified according to whether SCP was used and EM status. Measured outcomes included operative mortality, a composite of operative mortality, stroke, and temporary neurological dysfunction (composite outcome), re-intubation, length of stay (LOS), post-operative ventilator hours, and ICU hours. Potential selection bias was controlled by calculating each patient’s probability of being assigned to SCP based on 26 pre-operative risk factors using propensity score (PS) methods. Multivariable logistic regression analysis was used to model adverse outcomes as a function of SCP, EM status and their interaction, adjusted for the PS. Adjusted odds ratios (AOR) were formulated along with 95% confidence intervals.
Results: Operative mortality occurred in 33 patients (12.1%); 8.8% in patients with SCP vs. 22.1% in those without SCP. Overall, transient neurologic dysfunction occurred in 21 (7.7%) patients; 5.9% in patients with SCP vs. 13.2% in patients without SCP. Stroke occurred in 12 (4.4%) patients; 3.4% in patients with SCP vs. 7.4% in patients without SCP. In patients with SCP, EM procedures were associated with increases in operative risk and neurologic injury compared with EL. Without SCP, there was no difference between EM and EL. In the EL setting alone, SCP was associated with significant decreases in operative mortality and neurologic injury compared with no-SCP (see table).
Conclusion: Use of SCP confers superior neurologic protection and a survival advantage during Ao that is most apparent in the EL operative setting. A risk reduction was also observed in patients having SCP in EL vs. EM surgery that was not observed in the no-SCP patients. These data suggest that use of SCP as a means of neurologic protection during HCA in Ao may be beneficial in EL as well as EM operative settings.
| Outcome | Non-emergent SCP vs. emergent SCP (AOR | Non-emergent No-SCP vs. emergent No-SCP (AOR) | Non-emergent SCP vs. Non-emergent No-SCP (AOR) | Emergent SCP vs. emergent No-SCP (AOR) |
| Operative mortality | 0.25(0.08, 0.73)* | 1.63 (0.45, 5.91) | 0.17 (0.05, 0.64)* | 1.14 (0.39, 3.34) |
| Composite Outcome | 0.25 (0.11, 0.56)* | 1.00 (0.32, 3.20) | 0.32 (0.11, 0.93)* | 1.29 (0.51, 3.24) |
| Re-intubation | 0.15 (0.05, 0.44)* | 0.51 (0.09, 2.91) | 0.48 (0.09, 2.69) | 1.70 (0.53, 5.39) |
| LOS >7 days | 0.26 (0.13, 0.50)* | 0.27 (0.09, 0.79)* | 1.13 (0.46, 2.77) | 1.18 (0.47, 2.94) |
| ICU >48 hrs. | 0.42 (0.22, 0.81)* | 0.29 (0.09, 0.91)* | 1.00 (0.42, 2.35) | 0.70 (1.25, 1.91) |
| Vent. >24 hrs. | 0.30 (0.15, 0.58)* | 0.31 (0.10, 0.97)* | 0.95 (0.36, 2.51) | 0.99 (0.40, 2.47) |
*p<0.05
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