Percutaneous Common Carotid Artery Access for Cardiac Interventions in Infants Does Not Acutely Change Cerebral Perfusion.
Lahiri S, Qureshi AM, Justino H, Mossad EB.
Pediatr Cardiol. 2022 Jan;43(1):104-109. doi: 10.1007/s00246-021-02697-9. Epub 2021 Aug 7. PMID: 34363498
Take Home Points:
- NIRS can be used to assess regional cerebral oxygen saturation in patients receiving common carotid artery (CCA) vascular access in the congenital cardiac catheterization laboratory.
- There was no change in NIRS with CCA access during cardiac catheterization in neonates and infants.
- Further prospective studies are needed to understand trends of lower regional cerebral oxygen saturation with certain procedure lengths and cardiac physiologies.
Commentary from Dr. Arash Salavitabar (Columbus, OH, USA), section editor of Congenital Heart Disease Interventions Journal Watch:
The authors address the important and unknown impact of percutaneous common carotid artery (CCA) vascular access and cerebral perfusion in the cardiac catheterization laboratory using Near-Infrared Spectroscopy (NIRS) to assess regional cerebral oxygen saturation (rSO2). This was a single-center retrospective chart review at a large tertiary care center over a 10 year period. All patients who had ipsilateral cerebral NIRS monitored on the side of CCA access were included.
The typical institutional practice described by the authors was to place one NIRS probe on each side of the patient’s forehead if cardiac catheterization was being performed via CCA. NIRS data were collected continuously from 15 minutes prior until 15 minutes after the end of the procedure, and the mean NIRS were compared between pre-vascular access, during access, and following sheath removal. The primary outcome measure was the change in NIRS with CCA access. The secondary outcome measure was the area under the curve for rSO2 ≤ 45%, which was based off of thresholds of prior studies associated with neurodevelopmental outcomes. The value of “Integrated rSO2” (=minutes × (desaturation values ≤ 45%)) was chosen as a marker of neurodevelopmental outcomes, which was chosen over total duration of rSO2 ≤45% in order to better indicate the extent of desaturation below the threshold value.
This study included 21 patients. The median patient age was 23 days (IQR 7,79) and weight was 3.3 kg (IQR 2.8,2.9). The median sheath size was 4F (3.3–5F) and duration of the procedure was 1 h 48 min (range 22 min to 4 h). There was no significant difference found in mean NIRS before, during, or after the CCA catheterizations. Integrated rSO2 ≤ 45% was grouped into 3 groups (0 min, 0.1–39 min, ≥40 min). There were no significant differences in total integrated rSO2 ≤ 45%, total procedure duration, minimum integrated rSO2 ≤ 45%, average rSO2, or minimum rSO2 between the 3 groups. Of clinical importance, Group III had the longest procedure duration and lower average rSO2, of which one patient had an extremely low NIRS noted by the authors. When analyzing patients who had bilateral NIRS documented, neither integrated rSO2≤ 45% nor NIRS was significantly different between two sides during the procedure. Three total patients had significantly elevated integrated rSO2 ≤ 45%, two of which were thought to be secondary to ductal constriction, rather than CCA access.
This paper addresses an impactful topic that has not yet been fully explored. The authors provide important baseline findings that show that cerebral perfusion is not significantly or adversely affected in patients who receive CCA in the congenital cardiac catheterization laboratory. It is important to note that this study included a small sample size and was limited by retrospective data collection and analysis. To fully understand the trends seen in a small number of patients, it will be important to perform a prospective study evaluating CCA and markers of cerebral perfusion in a more rigorous way. Nonetheless, this data is an important first step to understanding the impact of this form of vascular access in what is often a fragile population.