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Microcirculatory perfusion shift in the gut wall layers induced by extracorporeal circulation Johannes Kalder, MD, Dieudonne Ajah, Paula Keschenau, MD, Lieven N. Kennes, PhD, Rene Tolba, MD, PhD, Maria Kokozidou, MD, PhD, Michael J. Jacobs, PhD, Thomas A. Koeppel, MD, PhD Journal of Vascular Surgery Volume 61, Issue 2, Pages 497-503 (February 2015) DOI: 10.1016/j.jvs.2013.10.070 Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 1 Sketch shows of the experimental setting of (a) group II and (b) group III. In group II, extracorporeal circulation (ECC) was performed through the external iliac vein and artery. In group III, an additional selective visceral perfusion (SVP) was performed through an octopus tubing system and balloon-blockable perfusion catheters. Journal of Vascular Surgery 2015 61, 497-503DOI: (10.1016/j.jvs.2013.10.070) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 2 Mean arterial blood pressure measurements were acquired by an intra-arterial line placed in the common carotid artery. At T2 and T3 (period of extracorporeal circulation [ECC]), the pressure was measured in an intra-aortic line placed below the thoracic aortic clamp (TAC) in group II, whereas the pressure values in group III were measured at the tip of the perfusion catheters of celiac trunk (CT) and superior mesenteric artery (SMA). DAP, Distal aortic perfusion; SVP, selective visceral perfusion. Journal of Vascular Surgery 2015 61, 497-503DOI: (10.1016/j.jvs.2013.10.070) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 3 Measured flow rates of the (a) celiac trunk (CT) and the (b) superior mesenteric artery (SMA) retrieved at the origins of the vessels by ultrasound flow probes. In group III at T2 and T3 (period of extracorporeal circulation [ECC]), flow rates were measured at the tubing system of the selective perfusion catheters. DAP, Distal aortic perfusion; SVP, selective visceral perfusion; TAC, thoracic aortic clamp. Journal of Vascular Surgery 2015 61, 497-503DOI: (10.1016/j.jvs.2013.10.070) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 4 Microcirculation measured with 15-μm fluorescent microspheres. To pool the microspheres correctly, they were injected into the descending aorta at T2 and T3 (period of extracorporeal circulation [ECC]) in cohort III into the extracorporeal tubing system, respectively. a, Perfusion is calculated for the entire gut wall. b, The ratio between the weight-corrected emanated fluorescence between the mucosal and the muscular layer is calculated. DAP, Distal aortic perfusion; SVP, selective visceral perfusion; TAC, thoracic aortic clamp. Journal of Vascular Surgery 2015 61, 497-503DOI: (10.1016/j.jvs.2013.10.070) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 5 Measurements of metabolic parameters were conducted repeatedly throughout the experiment: (a) aerobic marker oxygen extraction ratio and (b) anaerobic marker lactate levels. The oxygen extraction ratio was calculated from arterial and portal venous blood. DAP, Distal aortic perfusion; SVP, selective visceral perfusion; TAC, thoracic aortic clamp. Journal of Vascular Surgery 2015 61, 497-503DOI: (10.1016/j.jvs.2013.10.070) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 6 Portal venous pH levels were intermittently measured. DAP, Distal aortic perfusion; SVP, selective visceral perfusion; TAC, thoracic aortic clamp. Journal of Vascular Surgery 2015 61, 497-503DOI: (10.1016/j.jvs.2013.10.070) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 7 Portal venous plasma levels of intestinal fatty acid-binding protein (IFABP) were measured as a marker for mucosal damage. DAP, Distal aortic perfusion; SVP, selective visceral perfusion; TAC, thoracic aortic clamp. Journal of Vascular Surgery 2015 61, 497-503DOI: (10.1016/j.jvs.2013.10.070) Copyright © 2015 Society for Vascular Surgery Terms and Conditions