Original article: cardiovascular
Technical advances in total aortic arch replacement

Presented at the Thirty-ninth Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 31–Feb 2, 2003.
https://doi.org/10.1016/S0003-4975(03)01342-0Get rights and content

Abstract

Background

We compared the effects of using hypothermic circulatory arrest (HCA) alone, HCA combined with selective cerebral perfusion (SCP), and use of SCP with a trifurcated graft (T) on outcome after aortic arch repair.

Methods

One hundred fifty patients, median age 66 years (range, 27 to 85), underwent total arch replacement between 1988 and 2002; 75 were female. We retrospectively compared the results of three patient groups roughly comparable with regard to preoperative risk factors: 45 patients using HCA beginning in 1988; 67 patients using HCA/SCP beginning in 1994; and 38 patients utilizing a trifurcated arch graft in conjunction with SCP through the axillary artery (HCA/SCP/T) since 2000. The groups were well matched with regard to median age (66, 68, and 66 years), urgency (emergent 11%, 13%, 5%; urgent 24%, 9%, 18%; and elective 64%, 78%, 76%), and several other known risk factors (p = not significant).

Results

An adverse outcome—hospital death or permanent stroke—occurred in 14%: in 16% with HCA, in 16% with HCA/SCP, and in 8% with HCA/SCP/T. Transient neurologic dysfunction among patients surviving without stroke was lower with HCA/SCP/T (11%) than with HCA (33%) or HCA/SCP (17%). Mean duration of HCA was 52 ± 16 minutes with HCA alone versus 45 ± 10 minutes with HCA/SCP and 31 ± 7 minutes with HCA/SCP/T (p < 0.0001 for groups HCA and HCA/SCP combined versus HCA/SCP/T). Mean duration of SCP was 57 ± 25 minutes with HCA/SCP versus 62 ± 24 minutes with HCA/SCP/T (p = not significant). Comparison of the groups of patients who had comparable preoperative risk factors for adverse outcome showed a trend toward lower adverse outcome and transient neurologic dysfunction rates using HCA/SCP/T; a significant reduction in respiratory (p < 0.001), infectious (p = 0.015) and cardiac (p = 0.005) complications in HCA/SCP/T compared with the earlier groups; and significantly shorter durations of intensive care (p < 0.0001) and hospitalization (p = 0.004).

Conclusions

Our results suggest that HCA/SCP is superior to HCA alone for preventing cerebral injury during operations on the aortic arch. By further reducing embolic risk as well as duration of HCA, HCA/SCP/T with axillary artery cannulation may be the optimal technique for averting adverse outcomes, reducing complications, and shortening hospital stay after aortic arch repair.

Section snippets

Patients and methods

Between October 1988 and October 2002, 156 consecutive patients underwent total aortic arch replacement and various portions of the ascending and proximal descending aorta as well as the proximal part of the brachiocephalic branches utilizing three different techniques. When these groups were compared with regard to preoperative risk factors previously identified to increase adverse outcome, it was noted that there were no patients with hemodynamic compromise in group HCA/SCP/T. Therefore to

Comparability of experimental groups

The 112 patients who underwent operation using HCA alone or using the HCA/SCP technique—excluding the ones with preoperative hemodynamic compromise—were compared with the 38 patients in the HCA/SCP/T group with regard to preoperative variables that might have a significant impact on adverse outcome or temporary neurologic dysfunction. No significant differences were found with regard to sex, the proportion of patients with age exceeding 60 years, the presence of clot or atheroma in the aorta,

Comment

Various modifications of surgical technique and perfusion strategies have been introduced over the past few decades to reduce mortality and morbidity associated with aortic arch replacement 6, 13, 14, 15. Technical improvements in CPB, myocardial protection, and perioperative and intensive care have reduced adverse outcome associated with operations on the aortic arch [16]. Some of these factors as well as other changes that have little to do with operative technique (such as fiscal pressure to

Conclusions

Although our experience with aortic arch replacement using SCP and the trifurcated graft has been in relatively few patients, the results are promising: a reduction in adverse outcome and more subtle cognitive impairment and a significant improvement over earlier techniques in reducing complications and in shortening the duration of intensive care and hospitalization. We think that this strategy combined with axillary artery cannulation may be the optimal technique for maximizing cerebral

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Copyright © 2004 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.