A Technical Modification for Establishing Selective Antegrade Cerebral Perfusion during Pulmonary Endarterectomy
Andreas Boening1, Eckhard Mayer2
1Department Cardiovascular Surgery, Justus-Liebig-University, Giessen, Germany
2Department Thoracic Surgery, Thorax Center, Kerckhoff Clinic Bad Nauheim, Bad Nauheim, Germany
Address for correspondence
Prof. Dr. Andreas Boening, Department Cardiovascular Surgery, Justus-Liebig-University, Giessen, Germany
Prof. Dr. Eckhard Mayer, Department Thoracic Surgery, Thorax Center, Kerckhoff Clinic Bad Nauheim, Bad Nauheim, Germany (e-mail: andreas.boening@chiru.med.uni-giessen.de; thoraxchirurgie@kerckhoff-klinik.de).
The better is the enemy of the good.[1]
Progress in medicine has often come from questioning usual practices, aiming toward better solutions for our patients. In the era of “evidence-based medicine,” progress and success have to be measurable to show that “better is the enemy of the good.” Even in surgery, where eminence-based medicine relying on certain “schools” with traditional therapy forms is still more the rule than the exception, advantages and disadvantages of surgical techniques are subject to clinical studies using elaborate statistical methods for measurement of success of different techniques. During the last years, on-pump and off-pump coronary artery surgery have been compared using these methods, for example (GOPCABE study).
Also for the topic of this case report, namely, the surgical treatment of chronic thromboembolic pulmonary hypertension (CTEPH), there is a study comparing the approach suggested in this report with the standard technique (PEACOG).[2] The message from this study was that using the standard technique would make surgery easier, while safety was similar to the antegrade cerebral perfusion (ACP) technique.
As the standard technique involves deep hypothermic circulatory arrest (DHCA), it allows for periods without body perfusion of up to 20 minutes, after which a reperfusion is required. This reperfusion is markedly different from ACP, because ACP always requires manipulation of the head vessels with its inherent complications. Moreover, continuous ACP is leading to flow through the pulmonary vasculature, again leading to reduced visibility and worse exposure of the segmental and subsegmental pulmonary artery branches.
For these reasons, centers that do surgery for CTEPH routinely (which nowadays means > 100 cases/year) still rely on DHCA. The results of CTEPH surgery with DHCA are predictable, have low complication and mortality rates, and have a completely uneventful neurologic recovery of the patients.[3]
[4] There is international consensus that DHCA is the optimal concept for pulmonary endarterectomy surgery.[5]
[6] It seems that the “enemy of the good” still remains to be found in CTEPH surgery.
