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Editorial| Volume 36, ISSUE 6, P1519-1521, June 2022

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Neurovigilance in Aortovascular Perioperative Care: From Signaling to Decisions

Published:December 23, 2021DOI:https://doi.org/10.1053/j.jvca.2021.12.019
Neurovigilance in Aortovascular Perioperative Care: From Signaling to Decisions
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      NEUROLOGIC INJURY or permanent neurologic damage as a result of any surgery are devastating and often lethal complications. The central nervous system, comprising the brain and the spinal cord, stores no glucose, and, hence, it is vulnerable to ischemia.
      • Rothwell J
      • Antal A
      • Burke D
      • et al.
      Central nervous system physiology.
      Clin Neurophysiol. 2021; 132: 3043-3083
      In open surgery of the aortic arch and the great arteries, where the anatomic blood supply to the brain is expected to be interrupted by cross-clamping and transecting the ascending aorta, a variety of strategies have been instituted since 1970 to protect the brain by creating a low cerebral metabolic state, flush away debris and gas (air), and maintain cellular integrity.
      • Lai W-L
      • Hsu C-P
      • Shih C-C
      • et al.
      Selective cerebral perfusion with 4-branch graft total aortic arch replacement: Outcomes in 12 patients.
      J Cardiothorac Surg. 2012; 7: 32
      , 
      • Bachet J.
      What is the best method for brain protection in surgery of the aortic arch? Selective antegrade cerebral perfusion.
      Cardiol Clin. 2010; 28: 389-401
      , 
      • Ogino H
      • Sasaki H
      • Minatoya K
      • et al.
      Evolving arch surgery using integrated antegrade selective cerebral perfusion: Impact of axillary artery perfusion.
      J Thorac Cardiovasc Surg. 2008; 136 (discussion 948-9): 641-648
      , 
      • Safi HJ
      • Miller CC
      • Lee T-Y
      • et al.
      Repair of ascending and transverse aortic arch.
      J Thorac Cardiovasc Surg. 2011; 142: 630-633
      These strategies are based on hypothermic circulatory arrest, whereupon having previously instituted cardiopulmonary bypass, the body is cooled to a varying nadir core temperature while the cardiopulmonary bypass pump stops, to resume and rewarm after the repair of the proximal pathology (ascending aorta and head and neck arteries at the aortic arch) is completed. Hypothermic circulatory arrest offers a motionless, bloodless field; it minimizes aortic clamping and protects the central nervous system by reducing the cerebral metabolic rate, excitatory transmitter release, ion influx, and vascular permeability.
      • Lai W-L
      • Hsu C-P
      • Shih C-C
      • et al.
      Selective cerebral perfusion with 4-branch graft total aortic arch replacement: Outcomes in 12 patients.
      J Cardiothorac Surg. 2012; 7: 32
      , 
      • Bachet J.
      What is the best method for brain protection in surgery of the aortic arch? Selective antegrade cerebral perfusion.
      Cardiol Clin. 2010; 28: 389-401
      , 
      • Ogino H
      • Sasaki H
      • Minatoya K
      • et al.
      Evolving arch surgery using integrated antegrade selective cerebral perfusion: Impact of axillary artery perfusion.
      J Thorac Cardiovasc Surg. 2008; 136 (discussion 948-9): 641-648
      , 
      • Safi HJ
      • Miller CC
      • Lee T-Y
      • et al.
      Repair of ascending and transverse aortic arch.
      J Thorac Cardiovasc Surg. 2011; 142: 630-633
      It is understood that cerebral perfusion has a protective effect for stroke when adjunct to hypothermic circulatory arrest, and it currently is pursued by various configurations of antegrade and retrograde cerebral perfusion/cannulation.
      • Lai W-L
      • Hsu C-P
      • Shih C-C
      • et al.
      Selective cerebral perfusion with 4-branch graft total aortic arch replacement: Outcomes in 12 patients.
      J Cardiothorac Surg. 2012; 7: 32
      , 
      • Bachet J.
      What is the best method for brain protection in surgery of the aortic arch? Selective antegrade cerebral perfusion.
      Cardiol Clin. 2010; 28: 389-401
      , 
      • Ogino H
      • Sasaki H
      • Minatoya K
      • et al.
      Evolving arch surgery using integrated antegrade selective cerebral perfusion: Impact of axillary artery perfusion.
      J Thorac Cardiovasc Surg. 2008; 136 (discussion 948-9): 641-648
      , 
      • Safi HJ
      • Miller CC
      • Lee T-Y
      • et al.
      Repair of ascending and transverse aortic arch.
      J Thorac Cardiovasc Surg. 2011; 142: 630-633
      Retrograde cerebral perfusion is overall simpler but less convincing in terms of adequate global perfusion of the human brain.
      • Lai W-L
      • Hsu C-P
      • Shih C-C
      • et al.
      Selective cerebral perfusion with 4-branch graft total aortic arch replacement: Outcomes in 12 patients.
      J Cardiothorac Surg. 2012; 7: 32
      , 
      • Bachet J.
      What is the best method for brain protection in surgery of the aortic arch? Selective antegrade cerebral perfusion.
      Cardiol Clin. 2010; 28: 389-401
      , 
      • Ogino H
      • Sasaki H
      • Minatoya K
      • et al.
      Evolving arch surgery using integrated antegrade selective cerebral perfusion: Impact of axillary artery perfusion.
      J Thorac Cardiovasc Surg. 2008; 136 (discussion 948-9): 641-648
      ,
      • Lau C
      • Gaudino M
      • Mills Iannacone E
      • et al.
      Retrograde cerebral perfusion is effective for prolonged circulatory arrest in arch aneurysm repair.
      Ann Thorac Surg. 2018; 105: 491-497
      Brain protection in arch surgery depends on cerebral temperature, circulatory arrest time, and cerebral perfusion during circulatory arrest, and the mechanism of neural injury is multifactorial
      • Lou X
      • Chen EP.
      Optimal cerebral protection strategies in aortic surgery.
      Semin Thorac Cardiovasc Surg. 2019; 31: 146-152
      —it has been noted that most cerebrovascular events are embolic, and preoperative screening for preexisting stenoocclusions is not common, especially in acute aortic syndrome.
      • Catena E
      • Tasca G
      • Fracasso G
      • et al.
      Usefulness of transcranial color Doppler ultrasonography in aortic arch surgery.
      J Cardiovasc Med (Hagerstown). 2013; 14: 597-602
      The debate on the optimum strategy is stoked by the gradual expansion in surgery for acute aortic syndrome and other “aortopathies.” The definitive answer to that question probably is not imminent, and the interest in it increases with the expansion in aortovascular surgery. Such a debate is far from academic or theoretical, as the deployment of various strategies affects the complexity of the surgical setup, costs, and, ultimately, training and governance. The repercussions of accepting one algorithm over the others will be exponentially affecting the industry and, most importantly, the lives of “aortopaths”; it is a problem of weighing coagulopathy, increased length of surgery, and increased systemic inflammatory response with deeper degrees of hypothermia versus the potential benefits of better organ protection.
      The optimal temperature of hypothermic circulatory arrest and protocol for cerebral perfusion remain under debate.
      • Kamenskaya OV
      • Klinkova AS
      • Chernyavsky AM
      • et al.
      Deep hypothermic circulatory arrest vs. antegrade cerebral perfusion in cerebral protection during the surgical treatment of chronic dissection of the ascending and arch aorta.
      J Extra Corpor Technol. 2017; 49: 16-25
      , 
      • Svensson LG
      • Blackstone EH
      • Apperson-Hansen C
      • et al.
      Implications from neurologic assessment of brain protection for total arch replacement from a randomized trial.
      J Thorac Cardiovasc Surg. 2015; 150 (e11): 1140-1147
      , 
      • Urbanski PP
      • Lenos A
      • Lindemann Y
      • et al.
      Use of a carotid artery for arterial cannulation: side-related differences.
      Thorac Cardiovasc Surg. 2010; 58: 276-279
      , 
      • Svensson LG
      • Nadolny EM
      • Penney DL
      • et al.
      Prospective randomized neurocognitive and S-100 study of hypothermic circulatory arrest, retrograde brain perfusion, and antegrade brain perfusion for aortic arch operations.
      Ann Thorac Surg. 2001; 71: 1905-1912
      , 
      • Tanoue Y
      • Tominaga R
      • Ochiai Y
      • et al.
      Comparative study of retrograde and selective cerebral perfusion with transcranial Doppler.
      Ann Thorac Surg. 1999; 67: 672-675
      The risk of moderate levels of hypothermia is a reduction in the cerebral and visceral organ metabolic suppression in exchange for significantly shorter cooling and rewarming periods.
      • Luehr M
      • Bachet J
      • Mohr F-W
      • et al.
      Modern temperature management in aortic arch surgery: The dilemma of moderate hypothermia.
      Eur J Cardiothorac Surg. 2014; 45: 27-39
      Flushing debris by retrograde perfusion must be weighed against the risk of cerebral edema.
      • Broderick P
      • Damberg A
      • Ziganshin BA
      • et al.
      Alpha-stat versus pH-stat: We do not pay it much mind.
      J Thorac Cardiovasc Surg. 2018; 156: 41-42
      ,
      • Damberg A
      • Carino D
      • Charilaou P
      • et al.
      Favorable late survival after aortic surgery under straight deep hypothermic circulatory arrest.
      J Thorac Cardiovasc Surg. 2017; 154 (e1): 1831-1839
      The exact volumes and flows of fluids entering and exiting the cerebral circulation must be fastidiously monitored and actively modified in response to neuromonitoring. Antegrade cerebral perfusion is closer to physiologic cerebral blood flow, and the newer antegrade cerebral perfusion via the innominate artery avoids the risks posed to the brachial plexus by axillary artery inflow. The authors here observed the paucity of a detailed stepwise analysis of decision-making in terms of central nervous system protection and the Coselli statement on the prohibitive complexity of performing an adequately powered randomized trial.
      • Coselli JS
      • Green SY
      Evolution of aortic arch repair.
      Tex Heart Inst J. 2009; 36: 435-437
      It is of primary importance that cardiovascular anesthesiologists and cardiac intensivists develop an understanding and deep perioperative sense of the physiologic responses to major aortic surgery, risks of neurologic injury, and the strategies that potentially could mitigate neuronal insult. Importantly, the sustained increase in case volume dictates the need for neurovigilance in anesthesia and perioperative care for major aortic arch interventions.
      • Ghincea CV
      • Anderson DA
      • Ikeno Y
      • et al.
      Utility of neuromonitoring in hypothermic circulatory arrest cases for early detection of stroke: Listening through the noise.
      J Thorac Cardiovasc Surg. 2021; 162 (e5): 1035-1045
      There is a need for a validated stepwise perioperative algorithm for active central nervous system protection by neuromonitoring initiating changes to anesthesia, perfusion, and surgical management. The notion of integrating neuromonitoring of the brain and the spinal cord, applying the protocols of thoracic endovascular aortic repair, may be the natural next step.
      • Protopapas AD
      • Valchanov K
      • Catarino P
      • et al.
      Neuroprotection and the aorta: One system, one artery, one expectation, one team.
      J Cardiothorac Vasc Anesth. 2021; 35: 1189-1191
      There is an array of neuromonitoring data physicians should feel comfortable with.
      • Ghincea CV
      • Anderson DA
      • Ikeno Y
      • et al.
      Utility of neuromonitoring in hypothermic circulatory arrest cases for early detection of stroke: Listening through the noise.
      J Thorac Cardiovasc Surg. 2021; 162 (e5): 1035-1045
      ,
      • Li Y
      • Zhang D
      • Liu B
      • et al.
      Noninvasive cerebral imaging and monitoring using electrical impedance tomography during total aortic arch replacement.
      J Cardiothorac Vasc Anesth. 2018; 32: 2469-2476
      , 
      • Ghazy T
      • Darwisch A
      • Schmidt T
      • et al.
      The transcranial Doppler sonography for optimal monitoring and optimization of cerebral perfusion in aortic arch surgery: A case series.
      Heart Surg Forum. 2017; 20: E085-E088
      , 
      • Dubovoy A
      • Chang P
      • Persad C
      • et al.
      Forbidden word entropy of cerebral oximetric values predicts postoperative neurocognitive decline in patients undergoing aortic arch surgery under deep hypothermic circulatory arrest.
      Ann Card Anaesth. 2017; 20: 135-140
      , 
      • Bergeron EJ
      • Mosca MS
      • Aftab M
      • et al.
      Neuroprotection strategies in aortic surgery.
      Cardiol Clin. 2017; 35: 453-465
      , 
      • Murashita T
      • Pochettino A.
      Intraoperative electroencephalogram-guided deep hypothermia plus antegrade and/or retrograde cerebral perfusion during aortic arch surgery.
      Cardiol Clin. 2017; 35: 453-465
      , 
      • Keenan JE
      • Wang H
      • Ganapathi AM
      • et al.
      Electroencephalography during hemiarch replacement with moderate hypothermic circulatory arrest.
      Ann Thorac Surg. 2016; 101: 631-637
      , 
      • Keenan JE
      • Benrashid E
      • Kale E
      • et al.
      Neurophysiological intraoperative monitoring during aortic arch surgery.
      Semin Cardiothorac Vasc Anesth. 2016; 20: 273-282
      , 
      • Feyissa AM
      • Pochettino A
      • Bower TC
      • et al.
      Rhythmic electrographic discharges during deep hypothermic circulatory arrest.
      Clin Neurophysiol. 2016; 127: 1901-1906
      They must note the practical schism between emergency and planned aortic surgery and anesthesia because this battery of neuromonitoring is impractical to be available in most centers out-of-hours (particularly nights) and during emergency care for acute aortic syndrome (mostly type A acute aortic dissections).
      Therefore, one should never ignore signals that may herald neurodisability. False-negative reading may be attributable to human factors. Human operators are inclined to shut down unfamiliar signals. The need for understanding of and compliance with neurosignals in perioperative decision-making reminds us of an infamous incident: the signals from a novel SCR-270 radar set famously were ignored, and the consequences were dire!

      Loproto M. The radar warning that went unheeded. Available at: https://pearlharbor.org/warning-went-unheeded/. Accessed December 1, 2021.

      There is, therefore, a need for cardiovascular perioperative physicians to have training in and/or exposure to neuromonitoring and become familiar with the anatomic variabilities of the circle of Willis in humans.
      • Papantchev V
      • Stoinova V
      • Aleksandrov A
      • et al.
      The role of Willis circle variations during unilateral selective cerebral perfusion: A study of 500 circles.
      Eur J Cardiothorac Surg. 2013; 44: 743-753
      , 
      • Urbanski PP
      • Lenos A
      • Blume JC
      • et al.
      Does anatomical completeness of the circle of Willis correlate with sufficient cross-perfusion during unilateral cerebral perfusion?.
      Eur J Cardiothorac Surg. 2008; 33: 402-408
      , 
      • Merkkola P
      • Tulla H
      • Ronkainen A
      • et al.
      Incomplete circle of Willis and right axillary artery perfusion.
      Ann Thorac Surg. 2006; 82: 74-79
      This anatomic variability hinges on decision-making when neuromonitoring indicates unbalanced perfusion (eg, an increase in systemic and cerebral perfusion pressures and expeditious surgical debranching in response to lateralization of neuro-signals).
      • Merkkola P
      • Tulla H
      • Ronkainen A
      • et al.
      Incomplete circle of Willis and right axillary artery perfusion.
      Ann Thorac Surg. 2006; 82: 74-79
      , 
      • Li Y
      • Siemeni T
      • Optenhoefel J
      • Martens A
      • et al.
      Pressure level required during prolonged cerebral perfusion time has no impact on neurological outcome: A propensity score analysis of 800 patients undergoing selective antegrade cerebral perfusion.
      Interact Cardiovasc Thorac Surg. 2016; 23: 616-622
      , 
      • Endo H
      • Ishii H
      • Tsuchiya H
      • et al.
      Observations of retinal vessels during intermittent pressure-augmented retrograde cerebral perfusion in clinical cases.
      Interact Cardiovasc Thorac Surg. 2016; 23: 259-265
      , 
      • Endo H
      • Kubota H
      • Tsuchiya H
      • et al.
      Clinical efficacy of intermittent pressure augmented–retrograde cerebral perfusion.
      J Thorac Cardiovasc Surg. 2013; 145: 768-773
      , 
      • Loubser PG.
      Comparison of two sites of inflow pressure measurement during retrograde cerebral perfusion.
      J Cardiothorac Vasc Anesth. 2001; 15: 35-39
      , 
      • Verscheure D
      • Haulon S
      • Tsilimparis N
      • et al.
      Endovascular treatment of post type A chronic aortic arch dissection with a branched endograft: Early results from a retrospective international multicenter study.
      Ann Surg. 2021; 273: 997-1003
      , 
      • Tsagakis K
      • Dohle DS
      • Wendt D
      • et al.
      Left subclavian artery rerouting and selective perfusion management in frozen elephant trunk surgery.
      Minim Invasive Ther Allied Technol. 2015; 24: 311-316
      , 
      • Mavroudis CD
      • Molina E
      • Stewart A.
      Cerebral protection for aortic arch surgery: Hybrid approach.
      Semin Thorac Cardiovasc Surg. 2012; 24: 302-304
      Importantly, the ultrasonic imaging modalities (including transesophageal echocardiography) remain a useful adjunct in locating unstable atheroma in the arch and groin arteries and hence modifying manipulation of access and screening for debris and gas.
      • Catena E
      • Tasca G
      • Fracasso G
      • et al.
      Usefulness of transcranial color Doppler ultrasonography in aortic arch surgery.
      J Cardiovasc Med (Hagerstown). 2013; 14: 597-602
      ,
      • Urbanski PP
      • Lenos A
      • Kolowca M
      • et al.
      Near-infrared spectroscopy for neuromonitoring of unilateral cerebral perfusion.
      Eur J Cardiothorac Surg. 2013; 43: 1140-1144
      Similarly, the classic theory of spinal cord blood supply by the Adamkewicz artery is being challenged by the collateral network concept.
      • Katz ES
      • Tunick PA
      • Rusinek H
      • et al.
      Protruding aortic atheromas predict stroke in elderly patients undergoing cardiopulmonary bypass: Experience with intraoperative transesophageal echocardiography.
      J Am Coll Cardiol. 1992; 20: 70-77
      Given the practicalities and the relative risks, further clinical research should be done for elective total arch replacement and thoracic endovascular thoracic repair in high-volume centers. Exploring the utility of artificial intelligence and machine learning combined with a cost analysis of a fully integrated neuromonitoring bundle should be the focus of future “panaortic” research. Most important, researchers should explore the patient perspective (patient-reported outcomes), including the families of the neurodisabled individuals.

      Conflict of Interest

      None.

      References

        • Rothwell J
        • Antal A
        • Burke D
        • et al.
        Central nervous system physiology.
        Clin Neurophysiol. 2021; 132: 3043-3083
        View in Article
        • Lai W-L
        • Hsu C-P
        • Shih C-C
        • et al.
        Selective cerebral perfusion with 4-branch graft total aortic arch replacement: Outcomes in 12 patients.
        J Cardiothorac Surg. 2012; 7: 32
        View in Article
        • Bachet J.
        What is the best method for brain protection in surgery of the aortic arch? Selective antegrade cerebral perfusion.
        Cardiol Clin. 2010; 28: 389-401
        View in Article
        • Ogino H
        • Sasaki H
        • Minatoya K
        • et al.
        Evolving arch surgery using integrated antegrade selective cerebral perfusion: Impact of axillary artery perfusion.
        J Thorac Cardiovasc Surg. 2008; 136 (discussion 948-9): 641-648
        View in Article
        • Safi HJ
        • Miller CC
        • Lee T-Y
        • et al.
        Repair of ascending and transverse aortic arch.
        J Thorac Cardiovasc Surg. 2011; 142: 630-633
        View in Article
        • Lau C
        • Gaudino M
        • Mills Iannacone E
        • et al.
        Retrograde cerebral perfusion is effective for prolonged circulatory arrest in arch aneurysm repair.
        Ann Thorac Surg. 2018; 105: 491-497
        View in Article
        • Lou X
        • Chen EP.
        Optimal cerebral protection strategies in aortic surgery.
        Semin Thorac Cardiovasc Surg. 2019; 31: 146-152
        View in Article
        • Catena E
        • Tasca G
        • Fracasso G
        • et al.
        Usefulness of transcranial color Doppler ultrasonography in aortic arch surgery.
        J Cardiovasc Med (Hagerstown). 2013; 14: 597-602
        View in Article
        • Kamenskaya OV
        • Klinkova AS
        • Chernyavsky AM
        • et al.
        Deep hypothermic circulatory arrest vs. antegrade cerebral perfusion in cerebral protection during the surgical treatment of chronic dissection of the ascending and arch aorta.
        J Extra Corpor Technol. 2017; 49: 16-25
        View in Article
        • Svensson LG
        • Blackstone EH
        • Apperson-Hansen C
        • et al.
        Implications from neurologic assessment of brain protection for total arch replacement from a randomized trial.
        J Thorac Cardiovasc Surg. 2015; 150 (e11): 1140-1147
        View in Article
        • Urbanski PP
        • Lenos A
        • Lindemann Y
        • et al.
        Use of a carotid artery for arterial cannulation: side-related differences.
        Thorac Cardiovasc Surg. 2010; 58: 276-279
        View in Article
        • Svensson LG
        • Nadolny EM
        • Penney DL
        • et al.
        Prospective randomized neurocognitive and S-100 study of hypothermic circulatory arrest, retrograde brain perfusion, and antegrade brain perfusion for aortic arch operations.
        Ann Thorac Surg. 2001; 71: 1905-1912
        View in Article
        • Tanoue Y
        • Tominaga R
        • Ochiai Y
        • et al.
        Comparative study of retrograde and selective cerebral perfusion with transcranial Doppler.
        Ann Thorac Surg. 1999; 67: 672-675
        View in Article
        • Luehr M
        • Bachet J
        • Mohr F-W
        • et al.
        Modern temperature management in aortic arch surgery: The dilemma of moderate hypothermia.
        Eur J Cardiothorac Surg. 2014; 45: 27-39
        View in Article
        • Broderick P
        • Damberg A
        • Ziganshin BA
        • et al.
        Alpha-stat versus pH-stat: We do not pay it much mind.
        J Thorac Cardiovasc Surg. 2018; 156: 41-42
        View in Article
        • Damberg A
        • Carino D
        • Charilaou P
        • et al.
        Favorable late survival after aortic surgery under straight deep hypothermic circulatory arrest.
        J Thorac Cardiovasc Surg. 2017; 154 (e1): 1831-1839
        View in Article
        • Coselli JS
        • Green SY
        Evolution of aortic arch repair.
        Tex Heart Inst J. 2009; 36: 435-437
        View in Article
        • Ghincea CV
        • Anderson DA
        • Ikeno Y
        • et al.
        Utility of neuromonitoring in hypothermic circulatory arrest cases for early detection of stroke: Listening through the noise.
        J Thorac Cardiovasc Surg. 2021; 162 (e5): 1035-1045
        View in Article
        • Protopapas AD
        • Valchanov K
        • Catarino P
        • et al.
        Neuroprotection and the aorta: One system, one artery, one expectation, one team.
        J Cardiothorac Vasc Anesth. 2021; 35: 1189-1191
        View in Article
        • Li Y
        • Zhang D
        • Liu B
        • et al.
        Noninvasive cerebral imaging and monitoring using electrical impedance tomography during total aortic arch replacement.
        J Cardiothorac Vasc Anesth. 2018; 32: 2469-2476
        View in Article
        • Ghazy T
        • Darwisch A
        • Schmidt T
        • et al.
        The transcranial Doppler sonography for optimal monitoring and optimization of cerebral perfusion in aortic arch surgery: A case series.
        Heart Surg Forum. 2017; 20: E085-E088
        View in Article
        • Dubovoy A
        • Chang P
        • Persad C
        • et al.
        Forbidden word entropy of cerebral oximetric values predicts postoperative neurocognitive decline in patients undergoing aortic arch surgery under deep hypothermic circulatory arrest.
        Ann Card Anaesth. 2017; 20: 135-140
        View in Article
        • Bergeron EJ
        • Mosca MS
        • Aftab M
        • et al.
        Neuroprotection strategies in aortic surgery.
        Cardiol Clin. 2017; 35: 453-465
        View in Article
        • Murashita T
        • Pochettino A.
        Intraoperative electroencephalogram-guided deep hypothermia plus antegrade and/or retrograde cerebral perfusion during aortic arch surgery.
        Cardiol Clin. 2017; 35: 453-465
        View in Article
        • Keenan JE
        • Wang H
        • Ganapathi AM
        • et al.
        Electroencephalography during hemiarch replacement with moderate hypothermic circulatory arrest.
        Ann Thorac Surg. 2016; 101: 631-637
        View in Article
        • Keenan JE
        • Benrashid E
        • Kale E
        • et al.
        Neurophysiological intraoperative monitoring during aortic arch surgery.
        Semin Cardiothorac Vasc Anesth. 2016; 20: 273-282
        View in Article
        • Feyissa AM
        • Pochettino A
        • Bower TC
        • et al.
        Rhythmic electrographic discharges during deep hypothermic circulatory arrest.
        Clin Neurophysiol. 2016; 127: 1901-1906
        View in Article

      28. Loproto M. The radar warning that went unheeded. Available at: https://pearlharbor.org/warning-went-unheeded/. Accessed December 1, 2021.

        View in Article
        • Papantchev V
        • Stoinova V
        • Aleksandrov A
        • et al.
        The role of Willis circle variations during unilateral selective cerebral perfusion: A study of 500 circles.
        Eur J Cardiothorac Surg. 2013; 44: 743-753
        View in Article
        • Urbanski PP
        • Lenos A
        • Blume JC
        • et al.
        Does anatomical completeness of the circle of Willis correlate with sufficient cross-perfusion during unilateral cerebral perfusion?.
        Eur J Cardiothorac Surg. 2008; 33: 402-408
        View in Article
        • Merkkola P
        • Tulla H
        • Ronkainen A
        • et al.
        Incomplete circle of Willis and right axillary artery perfusion.
        Ann Thorac Surg. 2006; 82: 74-79
        View in Article
        • Li Y
        • Siemeni T
        • Optenhoefel J
        • Martens A
        • et al.
        Pressure level required during prolonged cerebral perfusion time has no impact on neurological outcome: A propensity score analysis of 800 patients undergoing selective antegrade cerebral perfusion.
        Interact Cardiovasc Thorac Surg. 2016; 23: 616-622
        View in Article
        • Endo H
        • Ishii H
        • Tsuchiya H
        • et al.
        Observations of retinal vessels during intermittent pressure-augmented retrograde cerebral perfusion in clinical cases.
        Interact Cardiovasc Thorac Surg. 2016; 23: 259-265
        View in Article
        • Endo H
        • Kubota H
        • Tsuchiya H
        • et al.
        Clinical efficacy of intermittent pressure augmented–retrograde cerebral perfusion.
        J Thorac Cardiovasc Surg. 2013; 145: 768-773
        View in Article
        • Loubser PG.
        Comparison of two sites of inflow pressure measurement during retrograde cerebral perfusion.
        J Cardiothorac Vasc Anesth. 2001; 15: 35-39
        View in Article
        • Verscheure D
        • Haulon S
        • Tsilimparis N
        • et al.
        Endovascular treatment of post type A chronic aortic arch dissection with a branched endograft: Early results from a retrospective international multicenter study.
        Ann Surg. 2021; 273: 997-1003
        View in Article
        • Tsagakis K
        • Dohle DS
        • Wendt D
        • et al.
        Left subclavian artery rerouting and selective perfusion management in frozen elephant trunk surgery.
        Minim Invasive Ther Allied Technol. 2015; 24: 311-316
        View in Article
        • Mavroudis CD
        • Molina E
        • Stewart A.
        Cerebral protection for aortic arch surgery: Hybrid approach.
        Semin Thorac Cardiovasc Surg. 2012; 24: 302-304
        View in Article
        • Urbanski PP
        • Lenos A
        • Kolowca M
        • et al.
        Near-infrared spectroscopy for neuromonitoring of unilateral cerebral perfusion.
        Eur J Cardiothorac Surg. 2013; 43: 1140-1144
        View in Article
        • Katz ES
        • Tunick PA
        • Rusinek H
        • et al.
        Protruding aortic atheromas predict stroke in elderly patients undergoing cardiopulmonary bypass: Experience with intraoperative transesophageal echocardiography.
        J Am Coll Cardiol. 1992; 20: 70-77
        View in Article

      Article info

      Publication history

      Published online: December 23, 2021

      Identification

      DOI: https://doi.org/10.1053/j.jvca.2021.12.019

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      © 2021 Elsevier Inc. All rights reserved.

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