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J Cardiothorac Surg
J Cardiothorac Surg
Journal of Cardiothoracic Surgery
1749-8090
BioMed Central London

3041
10.1186/s13019-024-03041-x
Case Report
Cerebral hypoperfusion resulting from improper cannulation positioning during aortic dissection surgery: a case report
Xia Qingping 1
Lin Fei 2
Cao Yong wildness@163.com

2
Deng Li dengli_198118@163.com

2
1 https://ror.org/05ptrtc51 grid.478001.a Department of science and education, The People’s Hospital of Gaozhou, Gaozhou, Guangdong China
2 https://ror.org/05ptrtc51 grid.478001.a Department of Cardiovascular Surgery, The People’s Hospital of Gaozhou, 89 Xiguan Rd, Gaozhou, Guangdong China
9 9 2024
9 9 2024
2024
19 52131 3 2024
31 8 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Background

Selective antegrade cerebral perfusion (sACP) is a crucial cerebral protection technique employed during aortic dissection surgeries involving cardiopulmonary bypass. However, postoperative neurological complications, particularly those related to cannulation issues and perfusion problems, remain a significant concern.

Case Presentation

This case report details an unusual instance where a 38-year-old male patient with Marfan syndrome experienced cerebral hypoperfusion during emergency surgery for Stanford Type A aortic dissection. Despite following standard protocols, a significant drop in regional cerebral oxygen saturation (rSO2) and abnormal blood pressure fluctuations were observed shortly after initiating sACP via the innominate artery. After initial attempts to optimize perfusion flow proved ineffective, the cannulation position was adjusted, leading to improvements. Nevertheless, the patient subsequently exhibited signs of cerebral hypoperfusion and was found to have suffered a new cerebral infarction.

Conclusions

This case report underscores the importance of precise cannula placement during sACP procedures and the dire consequences that can arise from improper positioning. It emphasizes the need for continuous monitoring and prompt intervention in cases of abnormal cerebral oxygenation and blood pressure, as well as the value of considering cannulation-related issues as potential causes of postoperative neurological complications.

Keywords

Aortic dissection
Anterograde cerebral perfusion
Hypoperfusion
Cannulation
the Project funded by China Postdoctoral Science Foundation2021M702780 This study was supported by grants from Guangdong Province major heart disease diagnosis and treatment engineering technology research center Program2017 issue-copyright-statement© BioMed Central Ltd., part of Springer Nature 2024
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pmcBackground

Selective antegrade cerebral perfusion (sACP) has become the standard approach for cerebral protection in aortic dissection (AD) surgeries involving cardiopulmonary bypass (CPB) [1]. Surgeons typically determine the use of unilateral or bilateral cerebral perfusion based on factors such as the anatomical integrity of the Willis circle, the configuration of the aortic arch branches, cerebral oxygen saturation, and the adequacy of blood return from the left common carotid artery during unilateral perfusion [2–4]. Despite advancements in cannulation techniques, postoperative neurological dysfunction remains a significant concern, often influenced by factors such as thrombotic events and perfusion issues [5, 6]. In this study, we present an uncommon case of cerebral perfusion insufficiency resulting from improper cannulation positioning. Additionally, we conducted a comprehensive literature review to summarize cases of cerebral perfusion insufficiency related to cannulation issues. Our aim is to provide clinicians with valuable insights to prevent similar complications and enhance patient outcomes.

Case presentation

A 38-year-old male patient presented to our hospital’s Emergency Department with persistent chest and back pain lasting for 20 days. The patient had no significant past medical history, but he fitted the criteria for Marfan syndrome, which runs in the family. Cardiac color Doppler ultrasound revealed dilation of the aortic sinus and ascending aorta. Computed tomography angiography (CTA) confirmed the diagnosis of type B aortic dissection (as shown in Fig. 1).

Fig. 1 The patient’s computed tomography angiography (CTA) image confirms that the patient has Stanford Type B dissection

During hospitalization, the patient’s blood pressure increased due to constipation, subsequently leading to worsening precordial pain, dyspnea, and other manifestations of dissection progression. Since conditions for another CTA were not available at that time and there were fears of death due to dissection rupture, we performed emergency surgery on the patient. Notably, throughout this process, the patient remained fully conscious. During the operation, we observed the formation of a hematoma in the ascending aorta, while no evidence of aortic dissection involving the arch branch vessels—namely, the innominate artery, left common carotid artery, and left subclavian artery—was detected. In summary, we determined that the patient had experienced a reverse dissection, progressing from type B dissection to type A dissection. The Echo-guided Seldinger technique facilitated cannulation of the ascending aorta in the case of type A aortic dissection.

Prior to the circulatory arrest, the patient’s nasal and anal temperatures were reduced to 24.4℃ and 27.8℃, respectively. sACP was initiated via cannulation of the innominate artery (brachiocephalic trunk) using a 14Fr cannula (Medtronic, USA). Preoperatively, regional cerebral oxygen saturation (rSO2) was measured at 70/72 (left/right). Immediately prior to circulatory arrest, the rSO2 decreased to 69/70, and the cerebral perfusion flow was set at 5 ml/kg/min.

However, within just 3 min of initiating sACP, a significant drop in rSO2 to 58/58 was observed, accompanied by a surge in right radial artery pressure (RRAP) to 62 mmHg. Attempts to increase the perfusion flow rate to 8 ml/kg/min failed to improve the rSO2, and instead, the blood pressure increased from 55 mmHg to 77 mmHg. The pump pressure fluctuated between 40 and 80 mmHg.

The observed abnormal changes in rSO2 and blood pressure necessitated prompt communication with the surgical team, prompting them to modify the cannulation position by retracting the cannula by 0.5 centimeters. Although the situation improved, these parameters remained below the normal range. Upon resuming systemic circulation and perfusion, the cerebral oxygen saturation rapidly returned to normal levels, increasing from 51/52 to 72/72 within 2 min.

The durations of CPB and aortic clamping were 155 min and 69 min, respectively. The total circulatory arrest time was 3 min, whereas the duration of sACP was 25 min. Postoperatively, the patient exhibited signs of cerebral hypoperfusion, manifesting as restlessness and confusion. We excluded factors related to narcotic drugs and confirmed the occurrence of new infarcts in the left frontal lobe through a CT scan of the patient’s brain. Electroencephalography (EEG) also revealed widespread and moderate abnormalities, including intermittent slow brain activity, suggesting the need for the start of symptomatic treatment.

In response to this condition, a comprehensive treatment approach was adopted, including cerebral protection measures, dehydration therapy, and pharmacological interventions to promote cerebral circulation recovery. Additionally, based on the patient’s specific manifestations of restlessness, appropriate analgesic and sedative treatments were administered to reduce cerebral oxygen consumption, maintain circulatory stability, and ensure the safety and security of all tubes and lines, thereby comprehensively supporting the patient’s postoperative recovery. On the fourth day following treatment, the patient regained consciousness and successfully underwent tracheal tube extraction on the fifth day. Given the patient’s irritability and manic depressive reactions, psychiatric consultation was sought. Subsequently, the patient recovered fully and was discharged from the hospital 18 days postoperatively (see Table 1 for timeline).

Table 1 Time line

Time	Events	
Day1	The patient was admitted with chest and back pain that lasted for more than 20 days. Meanwhile, the patient was diagnosed with type B aortic dissection based on ultrasound and CTA results.	
Day3	The type B aortic dissection transformed into type A due to heightened blood pressure triggered by difficulty with defecation.

The emergency surgery was performed immediately.

During sACP, it was found that there were abnormalities in cerebral oxygen and blood pressure. The doctor then investigated the cause and adjusted the position of the cannulation.

	
Day5	The patient exhibited postoperative clinical signs of cerebral hypoperfusion, including restlessness and confusion, and required treatment.	
Day7	Brain CT scans confirmed the development of a new cerebral infarction in the left frontal lobe. EEG revealed extensive and moderate EEG abnormalities, including intermittent slow activity throughout the brain, necessitating symptomatic treatment.	
Day17	The patient regained consciousness.	
Day18	The patient successfully underwent tracheal tube extraction, but due to the presence of irritability and manic depressive reactions, psychiatric consultation was recommended.	
Day21	The patient has successfully recovered and been discharged from the hospital.	

Discussion

In this case report, we present an uncommon but crucial instance of cerebral hypoperfusion resulting from improper cannulation positioning during sACP for Stanford Type A aortic dissection surgery (Fig. 2). This case highlights several key aspects that warrant further discussion and clinical implications.

Cannulation position and its impact on cerebral perfusion

The cannulation position during sACP is a critical factor influencing cerebral perfusion. In our case, the rapid decline in rSO2 and abnormal blood pressure fluctuations immediately following sACP initiation indicated a perfusion issue. Upon adjustment of the cannulation position, there was an improvement in these parameters, albeit not immediately to normal levels. This underscores the importance of precise cannula placement and continuous monitoring during sACP procedures.

Delayed diagnosis and the consequences

The initial delay in diagnosing cannula malposition led to a significant time consumption before effective intervention could be undertaken. This delay likely contributed to the patient’s postoperative cerebral hypoperfusion and the development of a new cerebral infarction. The case emphasizes the need for prompt communication between surgical and perfusion teams, as well as a low threshold for investigating cannulation-related issues when abnormal cerebral oxygenation or blood pressure is observed.

Circle of Willis integrity and perfusion strategy

The integrity of the circle of Willis is an important consideration in determining the adequacy of unilateral or bilateral cerebral perfusion [7, 8]. In our case, the lack of preoperative cerebrovascular assessment limited our understanding of the patient’s cerebrovascular anatomy. Had the circle of Willis been assessed and found to be incomplete, bilateral cerebral perfusion may have been initiated earlier, potentially reducing the risk of postoperative neurological complications.

Continuous monitoring and prompt intervention

Continuous monitoring of cerebral oxygenation and blood pressure throughout the surgical procedure is paramount [9]. In our case and those reported in the literature, abnormal changes in these parameters often preceded the onset of cerebral perfusion insufficiency [10, 11]. Prompt intervention, such as adjusting cannulation position or switching to bilateral cerebral perfusion, can mitigate the risk of neurological injury.

Literature review and clinical implications

Our literature review revealed nine relevant cases of cerebral hypoperfusion related to inappropriate cannulation during sACP(refer to Table 2). The majority of these cases were detected early during cardiopulmonary bypass (CPB) and were resolved through prompt intervention. These findings reinforce the importance of considering cannulation malfunction as a primary cause of abnormal cerebral oxygenation and blood pressure.

Furthermore, the review highlights the need for comprehensive preoperative assessment, including cerebrovascular imaging, to inform perfusion strategy. Surgeons should be vigilant during cannula placement, ensuring proper depth, orientation, and fixation to prevent displacement.

Clinical recommendations

Based on our case and the literature review, we recommend the following clinical practices:

Preoperative Assessment: Comprehensive preoperative cerebrovascular imaging to assess the integrity of the circle of Willis and aortic arch branches.

Continuous Monitoring: Continuous monitoring of cerebral oxygenation and blood pressure throughout the surgical procedure.

Prompt Intervention: A low threshold for investigating cannulation-related issues and prompt intervention, such as adjusting cannulation position or switching to bilateral cerebral perfusion, when abnormal monitoring parameters are observed.

Multidisciplinary Communication: Enhanced communication between surgical, perfusion, and anesthesia teams to ensure prompt diagnosis and intervention.

In conclusion, this case report underscores the importance of precise cannula placement and continuous monitoring during sACP procedures for aortic dissection surgery. Prompt intervention in cases of abnormal cerebral oxygenation and blood pressure, along with comprehensive preoperative assessment, can significantly reduce the risk of postoperative neurological complications.

Fig. 2 The illustrative diagram depicts the inferred causes of cerebral perfusion insufficiency in this patient. Arrow 1 indicates that the cannula might have been erroneously inserted into the subclavian artery or its outlet directed towards the left subclavian artery, ultimately leading to insufficient cerebral perfusion. Arrow 2 suggests the possibility of incomplete Willis’ circle in the patient

Table 2 Baseline characteristics and clinical prognosis of 9 cases

Author	Cannulation method	Dissection characteristic	Reason for cerebral hypoperfusion	Monitoring	Solutions and prognosis	
Imanaka

J.Thorac Cardiovasc Surg. 2000. [12]

	RAAC	The dissection encompassed the entire right CCA, extending circumferentially to the IA and nearing its bifurcation into the right carotid and subclavian arteries.	Obstruction of the true lumen due to perfusion through the RAAC	None	None;

Patient died due to cerebral hypoperfusion and was not found without monitoring

	
Schachner

Eur J Cardio-thorac Surg. 2005. [13]

	RAAC	Not described	Significant resistance in the artery during advancement of the cannula in one case;

Insufficient CPB flow at the beginning

	Decreasing LRAP and femoral artery pressure	Conversion from RAAC to FAC;

Alive and discharged

	
Shimokawa

Ann Thorac Surg. 2008. [14]

	FAC	Not described	Obstruction of the true lumen by TEE at the initiation of CPB.	No pressure of right radial artery after perfusion	Switched to transventricular cannulation immediately;

Alive and discharged without complications and neurologic sequelae

	
Imanaka

Ann Thorac Surg. 2014. [15]

	FAC	Bilateral carotid artery dissection; the true lumen of the innominate and right common carotid arteries had adequate width, and no flow was detected in the false lumen	FAC caused right cerebral hypoperfusion	rSO2 reducing	Additional RAAC perfusion (ineffective);

Snaring IA (effective);

Alive and discharged

	
Orihashi K

J Cardiothorac Vasc Anesth. 2006 [16]

	RAAC	Dissection was present in the proximal portion of the IA	RAAC perfusion led to hypoperfusion of the right frontal lobe	rSO2 reducing < 55%	Addition of LAAC perfusion;

Speech disturbance postoperatively and segmental cerebral infarction in the right frontal lobe, probably caused by embolism.

	
OrihashiK

J Thorac Cardiovasc Surg. 2009 [17]

	RAAC	A dissection and narrow true lumen of the proximal IA, compressed by false lumen	hypoperfusion after RAAC resulting from the narrowing of the IA lumen.	Right orbital flow reducing;

RAAP was lower than the dorsalis pedis artery pressure by 20 mmHg

	Addition of LAAC;

Recovered without complications.

	
Tetsuro Uchida

Kyobu Geka. 2012 [18]

	RAAC	Not described	hypoperfusion occurred after initiation	rSO2 reducing	Conversion from RAAC to FAC;

Recovered

	
Matsuoka

Kyobu Geka. 2013 [19]

	RCCA + RFAC + LAAC	Dissection involved the entire RAAC, and its false lumen extremely compressed the true lumen	Preoperative cerebral hypoperfusion due to persistent true lumen obstruction by the expanded false lumen in the IA	rSO2 reducing	Ascending aorta-right carotid artery bypass using the side branch was performed immediately;

recovered

	
Chan CK

Can J Anaesth 2014 [20]

	FAC; Catheters in LCCA and brachiocephalic for ACP	Dissection involving the brachiocephalic trunk, left common carotid artery, and left subclavian artery	hypoperfusion of as the tip of the brachiocephalic cannula had advanced into the right subclavian artery	rSO2 reducing	Withdrawal of the cannula into the brachiocephalic;

resolved and recovered

	

Acknowledgements

None.

Author contributions

LD: Concept/design, drafting article, critical revision of article, approval of article. QPX : Drafting article, critical revision of article, approval of article. , YC: revision of the article, and approval of the article. FL: Concept/design, critical revision of article, approval of article. All authors read and approved the final manuscript.

Funding

This study was supported by grants from Guangdong Province major heart disease diagnosis and treatment engineering technology research center Program (2017), and the Project funded by China Postdoctoral Science Foundation (2021M702780).

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Consent was obtained from the patient for the publication of this report.

Competing interests

The authors declare no competing interests.

Abbreviations

sACP Selective antegrade cerebral perfusion

rSO2 Regional cerebral oxygen saturation

AD Aortic dissection

CPB Surgeries involving cardiopulmonary bypass

CT Computerized tomography

EEG Electroencephalography

RRAP Right radial artery pressure

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Qingping Xia and Fei Lin contributed equally to this work.
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