The authors do not have any conflict of interest to declare.
We carefully read the recent paper by
Williams
et al. (1) on the innominate artery dissection during antegrade
selective cerebral perfusion (ASCP) through right axillary artery.
ASCP is considered the safest method of brain protection during aortic
arch surgery (2). It can be employed to perfuse both cerebral
hemispheres (bilateral cerebral perfusion) or just one (unilateral
cerebral perfusion). Currently available evidence supports that both
strategies are safe and guarantee satisfactory efficacy in terms of
brain protection (3). Neverthless, an ongoing debate about which
technique yields the best clinical outcomes is still open.
Bilateral antegrade selective cerebral perfusion (b-ACP) has the
undisputed advantage of being more physiological and theoretically
ensuring complete perfusion of the whole brain. However, it requires
longer execution times, manipulation of the vessels and often blind
insertion of endoluminal cannulae. On the other hand, unilateral
selective cerebral perfusion (u-ASCP) avoids the vessels manipulation,
placement of catheters into the ostia of the great vessels which
clutters the operative field and incurs both atherosclerotic and air
embolism risk. Regarding u-ASCP, few data is still available in
comparison to b-ACP, but the results look promising. In 2015 Angeloni et
al. (4) published a systematic review and meta‐analysis comparing u-ASCP
and b-ASCP. Although they concluded that there is no difference between
two techniques, a clear trend in favour of u-ASCP was showed, since all
the absolute values were lower than b-ASCP. Indeed, a mortality rate of
9.8%, a PND rate of 6.9% and a TND rate of 9.3%, were reported for
b-ASCP, while for u-ASCP they were 7.6%, 5.8%, and 6.5%,
respectively. Following the growing experience and the good results
obtained in aortic surgery, an increasing number of centres have begun
to adopt u-ASCP, highlighting the suitability of this strategy as a key
to reduce neurological complications, thanks to its simplicity and its
lower manipulation of the arch branch vessels (5,6).
The case described by Williams and colleagues (1) suggests few more
considerations.
Firstly, the importance of avoiding the manipulation of epiarotic
vessels during aortic surgery of both aortic aneurysm and dissections.
Secondly, this case can enrich the literature on this topic, supporting
the safety of u-ASCP also in complicated scenarios. Thirdly, cerebral
alterations during aortic arch surgery are generally attributed to the
use of cardiopulmonary bypass even if the cause of cerebral injury is
probably multifactorial, including the heterogeneity of this population
of patients and the surgical procedures themselves.
Lastly, as Williams et al. (1) have explained, only a full and
technological monitoring can help to recognized and promptly treat any
complications.
REFERENCES
- Williams DM, Masuno K, Kanchuger MS, Hisamoto K. Innominate artery
dissection due to selective cerebral antegrade perfusion. J Card Surg.
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33403684.
- Di Eusanio M, Schepens MA, Morshuis WJ, Dossche KM, Di Bartolomeo R,
Pacini D, Pierangeli A, Kazui T, Ohkura K, Washiyama N. Brain
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During Aortic Surgery: An Updated Meta-Analysis. Ann Thorac Surg. 2015
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Apr 16. PMID: 25890664.
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Apr;147(4):1212-7; discussion 1217-8. doi:
10.1016/j.jtcvs.2013.12.022. Epub 2014 Jan 2. PMID: 24507981.