Separate grafts or en bloc anastomosis for arch vessels reimplantation to the aortic arch

Branch-first aortic arch replacement strategy decreases perioperative mortality

OBJECTIVE

Sparce evidence suggests superiority of total arch replacement with the branch-first technique and antegrade cerebral perfusion over conventional techniques with respect to morbidity and mortality. Thus, we aimed to compare perioperative outcomes of patients undergoing traditional total arch replacement versus branch-first total arch replacement.

METHODS

We retrospectively reviewed 144 patients undergoing total arch replacement from January 2017 to December 2021. Patients were dichotomized based on technique, either traditional total arch replacement or branch-first total arch replacement. Primary end points were 30-day mortality and adverse events. Branch-first total arch replacement and traditional total arch replacement cohorts were compared using Student t tests and chi-square tests. Univariable and multivariable logistic regressions were performed to identify risk factors associated with 30-day mortality.

RESULTS

A total of 68 patients (47.2%) underwent traditional total arch replacement, and 76 patients (52.8%) underwent branch-first total arch replacement. The branch-first total arch replacement cohort had higher rates of chronic kidney disease, hypertension, atrial fibrillation, and previous myocardial infarction (P = .04, .002, .035, and .031 respectively). The majority of total arch replacements (78, 55%) were performed for aneurysmal disease. Median antegrade cerebral perfusion times were significantly shorter in the branch-first total arch replacement cohort (P = .001). There were no significant differences in rates of stroke, reintubation, postoperative lumbar drainage, renal failure, reoperation for bleeding, or prolonged ventilation between total arch replacement cohorts. The branch-first total arch replacement group had significantly lower 30-day mortality compared with the traditional total arch replacement group (4% vs 19%, P = .004). After adjustment for chronic kidney disease, nonelective status, antegrade cerebral perfusion time, rates of dissections arriving in extremis or with malperfusion, and primary surgeon, undergoing a branch-first total arch replacement was associated with a 93% reduced odds of 30-day mortality (odds ratio, 0.07, 95% CI, 0.009-0.48, P = .007).

CONCLUSIONS

We provide evidence that branch-first total arch replacement significantly reduces 30-day mortality compared with traditional total arch replacement.

Short- and long-term results of total arch replacement: Comparison between island and debranching techniques

OBJECTIVE

The 2 most acceptable techniques for reimplantation of the supra-aortic vessels in total arch replacement include the branched graft technique (debranching) or en bloc technique (island). We aim to review our experience with total arch replacement and report short- and long-term outcomes from a high-volume center dedicated to surgery for the thoracic aorta.

METHODS

The aortic surgery database was queried to identify all consecutive patients undergoing total arch replacement between 1997 and 2022. Of the 426 patients who underwent total arch replacement, 303 (71%) received the island technique and 123 (29%) received the debranching approach. Operative and long-term outcomes were compared using multivariable models.

RESULTS

The debranching group was younger (64 ± 14 years vs 69 ± 12 years, P = .001), had undergone more previous cardiac operations (54.5% vs 27.4%, P < .001), and had more connective tissue disorder (20.3% vs 4.6%, P < .001). The debranching approach was associated with longer total circulatory arrest time (47 ± 15 minutes vs 37 ± 10 minutes, P < .001) and cardiac ischemic time (116 ± 41 minutes vs 100 ± 37 minutes, P < .001). More patients in the debranching group received blood products intraoperatively or postoperatively (56.1% vs 42.9%, P = .018). All other early outcomes did not differ between groups. Overall operative mortality was 1.4% (2.4% vs 1%, P = .486); the incidence of major postoperative complications was 6.3% (5.7% vs 6.6%, P = .897). Ten-year survival was 80% (78% vs 80.9%, log-rank P = .356). Multivariable Cox regression analysis demonstrated that neither surgical approach was associated with survival advantage (hazard ratio, 1.18; 0.73-1.89; P = .495).

CONCLUSIONS

Debranching requires a longer operative time, with similar early and long-term outcomes. Preoperative comorbidity, not surgical technique, predicts major adverse events and long-term survival.

Normothermic frozen elephant trunk: our experience and literature review

BACKGROUND AND OBJECTIVE

The frozen elephant trunk (FET) technique has undoubtable advantages in treating complex and extensive disease of the aortic arch and the thoracic descending aorta. Despite several improvements in cardiopulmonary bypass conduction and surgical strategy, operative times and the institution of systemic circulatory arrest remain the main determinants of early mortality, cerebral/spinal cord injury and visceral organs dysfunction. We have conducted this review to highlight the recent technical advances in arch and FET surgery aiming at the reduction/avoidance of systemic circulatory arrest, and their impact on early outcomes.

METHODS

A literature search (from origin to January 2022), limited to publications in English, was performed on online platforms and database (PubMed, Google, ResearchGate). After a further review of associated or similar papers, we found 4 experiences, described by 11 peer-reviewed published papers, which focused on minimising or avoiding systemic circulatory arrest during total arch replacement plus stenting of the descending thoracic aorta.

KEY CONTENT AND FINDINGS

Recent experiences reported the use of an antegrade endoaortic balloon, advanced and inflated into the stent graft, to provide an early systemic reperfusion soon after the deployment of the stented portion of the FET prosthesis and minimize the circulatory arrest time (down to a mean of 5 minutes), thus avoiding the need of moderate or deep hypothermia (mean systemic temperature 28-30 °C) while allowing a complete arch and FET repair. Our approach, based on off-pump retrograde vascular stent graft deployment in distal arch/descending thoracic aorta, and the use of a retrograde endoballoon, allows the repair of extensive aortic pathologies during uninterrupted normothermic cerebral and lower body perfusion.

CONCLUSIONS

The use of endoballoon occlusion has emerged in recent years as a safe and effective strategy to allow distal perfusion during FET repair. This technique minimizes or avoids the detrimental effects of hypothermia and systemic circulatory arrest and significantly reduces the operative times.

[Predictors of early adverse events after the frozen elephant trunk procedure]

AIM

The aim of this study was to identify predictors of adverse events after the frozen elephant trunk procedure in the early postoperative period.

PATIENTS AND METHODS

Between March 2012 and March 2020, a total of 273 patients were operated on for aortic pathology. A retrospective analysis aimed at identifying probable predictors was performed on 83 patients who underwent the FET procedure. Uni- and multivariate logistic regression was used to identify predictors of such adverse events as postoperative delirium, respiratory failure, acute kidney injury, and in-hospital mortality.

RESULTS

According to the findings of the optimal multivariate regression model, separate reimplantation of the supra-aortic branches was a significant predictor of postoperative delirium (OR 10.41; 95% CI 1.1-35.45; p=0.05); significant risk factors for prolonged respiratory support were the duration of surgery (OR 1.02; 95% CI 1.01-1.03; p<0.001) and postoperative acute renal injury (OR 8.72; 95% CI 1.67-57.38; p=0.014). Independent risk factors for postoperative renal injury turned out to be the true lumen diameter of the descending aorta (OR 1.3; 95% CI 1.1-1.72; p=0.015) and chronic type A aortic dissection (OR 44.07; 95% CI 3.29-2354.8; p=0.014); statistically significant risk factors for in-hospital mortality were multiple organ dysfunction syndrome (OR 14.34; 95% CI 1.69-155.48; p=0.016) and coronary artery stenosis (OR 3.36; 95% CI 1.19-13.26; p=0.042).

CONCLUSION

Separate reimplantation of the supra-aortic branches, duration of surgery, acute kidney injury, chronic aortic dissection, multiple organ dysfunction syndrome, true lumen diameter of the descending aorta, coronary atherosclerosis and haemoglobin level were statistically significant predictors of adverse events in the early postoperative period.

Outcomes of different aortic arch replacement techniques

Background

Consensus on the best treatment for aortic arch pathology is unresolved due to an emerging variety of procedures. We aimed to compare the outcomes of two major techniques for open aortic arch replacement involving the supra‐aortic branches and to identify the risk factors for specific adverse events.

Methods

Between 1974 and 2017, 172 patients were treated with either the en bloc (island, n = 59; 34.3%) or branched graft technique (n = 113, 65.7%). Most of the patients were treated in an emergent/urgent setting (52.4%).

Results

Patients who underwent the en bloc procedure had significantly shorter cardiopulmonary bypass (median: 241 vs 271 minutes, P = .041) and aortic cross clamp times (median: 124 vs 168 minutes, P = .005) than patients who underwent the separate graft technique. Overall, the hospital mortality was lower in the en bloc group, 8.5% vs 19.5%, although the difference was not significant (P = .077). No difference was found in the survival between the separate graft and en bloc groups at 1 (77.0 vs 86.3%), 5 (67.7 vs 66.3%) and 10 years (42.4 vs 51.3%), (P = .63). The postoperative stroke rate was comparable between the en bloc and separate graft cohorts (14.3 vs 19.6%, P = .52). Diabetics and those who underwent an elephant trunk procedure were at a higher risk for reintervention.

Conclusions

The separate graft technique, which is more common today, showed no difference from the en bloc technique with regard to hospital mortality and morbidity. Furthermore, the late survival and reintervention rates were similar after both procedures.

Prognostic factors for permanent neurological dysfunction after total aortic arch replacement with regional cerebral oxygen saturation monitoring

OBJECTIVE

To explore the prognostic factors for permanent neurological dysfunction (PND) after total aortic arch replacement with regional cerebral oxygen saturation (rSO₂ ) monitoring.

METHODS

This retrospective study enrolled 98 type A aortic dissection aneurysm patients who underwent emergency total aortic arch replacement combined with deep hypothermic circulatory arrest and right axillary artery selective antegrade cerebral perfusion (SACP). Data such as age, gender, body mass index, preoperative coexisting disease, laboratory test results, intraoperative critical operation duration, and intraoperative rSO₂ were collected, and the neurological prognoses in the hospital were recorded and grouped by severity. Multiple logistic regression analysis was performed on the statistically significant differences between the groups to screen the predictors of postoperative neurological complications in these patients.

RESULTS

Forty-two patients had postoperative neurological complications, among which there were 29 cases (29.6%) of transient neurological dysfunction, and 13 cases (13.3%) of PND. Multiple logistic regression results showed that advanced age, preoperative low platelet count, prolonged hemostasis time and lowest relative rSO₂ to baseline (ΔrSO₂ min) in each time period were risk factors for postoperative PND. The ROC curve measurement showed that the optimal cut-off value of ΔrSO₂ min was 79.7%, and the area under the curve was 0.708 (95% confidence interval = 0.557-0.858), p = 0.016; the optimal cut-off value of ΔrSO₂ min in SACP was 81.6%, and the area under the curve was 0.720 (95% confidence interval = 0.570-0.870), p = 0.011; the optimal cut-off value of ΔrSO₂ min in cardiopulmonary bypass (CPB) was 80.8%, and the area under the curve was 0.697 (95% confidence interval = 0.554-0.840), p = 0.023.

CONCLUSION

Intraoperative ΔrSO₂ min that is lower than the basal level of about 80%, advanced age, preoperative low platelet count, and prolonged hemostasis time are predictors of PND after total aortic arch replacement.

Frozen elephant trunk with modified en bloc arch reconstruction and left subclavian transposition for chronic type A dissection

Background

Several methods of arch vessel reconstruction, such as en bloc (island) and branched graft techniques, have been proposed to treat aortic arch pathologies during total arch replacement (TAR). We seek to review our experience with modified en bloc technique and left subclavian (LSCA)-left carotid artery (LCCA) transposition in TAR and frozen elephant trunk (FET) procedure for chronic type A aortic dissection (CTAAD).

Methods

From September 2010 to September 2016, 35 consecutive patients with CTAAD underwent modified en bloc arch reconstruction with LSCA-LCCA transposition during TAR and FET procedure. Computed tomographic angiography (CTA) was performed during follow-up.

Results

In-hospital mortality was 5.7% (2/35). No neurological deficit or spinal cord injury occurred. Re-exploration for bleeding and continuous renal replacement therapy were required in 2 patients each (5.7%). Follow-up was complete in 100% for a mean duration of 4.1±1.8 years (range, 0.5-6.7 years). One patient experienced a transient stroke and thoracoabdominal aortic replacement was performed in 1. There were 2 late non-cardiac deaths. Survival was 87.9% (95% CI, 70.7-95.3%) at 6 years. At 6 years, the incidence was 3% for reoperation, 12% for late death, and 85% of patients were alive without reoperation. The anastomosis between the LSCA and LCCA was patent in 100%.

Conclusions

Acceptable early and mid-term outcomes were achieved for patients with chronic type A dissection using en bloc technique with LSCA-LCCA transposition during TAR and FET procedure. This technique may be an alternative approach to chronic type A dissection in selected patients.

[Brachiocephalic artery-sparing aortic arch repair combined with stent-graft elephant trunk technique for Stanford type A aortic dissection: analysis of 23 cases]

OBJECTIVE

To assess the clinical outcomes of brachiocephalic artery-sparing aortic arch repair combined with stent-graft elephant trunk technique for treatment of Stanford type A aortic dissection.

METHODS

Twenty-three patients with Stanford type A aortic dissection requiring arch replacement underwent brachiocephalic artery-sparing aortic arch repair combined with stent-graft elephant trunk technique. The operations were performed within 72 h (20 cases) or 3-14 days (3 cases) after the onset of aortic dissection.

RESULTS

There was no perioperative death in these cases. The mean extracorporeal circulation time was 209∓52 min, the aortic cross clamp time was 85∓21 min, and the mean chest tube output within the first 24 h after the operation was 570∓263 mL; none of the patients required chest reopening for management of bleeding. Postoperative acute renal failure requiring hemodialysis occurred in 3 cases, transient neurologic dysfunction in 2 cases, paraplegia in case and hematosepsis in 1 case. No such complications as permanent neurologic deficit or postoperative visceral malperfusion occurred in these cases. All the patients survived and were discharged from hospital without experiencing severe complications in the follow-up for 6-18 months.

CONCLUSION

Brachiocephalic artery-sparing aortic arch repair combined with stent-graft elephant trunk technique is a safe and simple procedure with controllable bleeding and can serve as an optional procedure for aortic arch replacement.

Open Stented Grafts for Frozen Elephant Trunk Technique: Technical Aspects and Current Outcomes

With growing experience in patients with aneurysms and dissections in the arch and proximal descending aorta, the frozen elephant trunk (FET) technique has been shown to be safe and effective, and has achieved favorable short to mid-term outcomes. As the FET technique is gaining wider acceptance, there is a growing need for versatile, technically simple, and highly durable open stented grafts involving less complicated deployment mechanisms enabling use in various indications. This paper gives a brief review on the technical aspects and clinical outcomes of currently available open stented grafts used in the FET technique, including the E-vita Open Plus, Thoraflex Hybrid, Cronus, and J Graft. While none of these grafts can claim to be an ideal device, technology continues to improve towards this goal. As newer devices and systems are developed, more widespread use of the FET technique can be expected; such progress promises to improve the clinical outcomes and quality of life for patients with complex aortic diseases.

Total arch replacement with separated graft technique and selective antegrade cerebral perfusion

It is essential to select the optimum method of cerebral protection and operative technique for arch repair to improve the surgical outcome of arch aneurysm or dissection. Selective antegrade cerebral perfusion (SACP) is our current method of choice if required cerebral protection time exceeds 30 minutes. Moderate hypothermic two-arch vessel perfusion (innominate artery or right axillary artery and left common carotid artery) is safe and effective for brain protection in a majority of patients. The separated graft technique using 4-branched graft is now our preferred surgical procedure used for arch aneurysm or dissection because this technique presents several advantages over the en-bloc or island technique. SACP allows us to perform meticulous arch repair and facilitates the time-consuming total arch replacement for complex aortic arch pathology and results in an acceptable mortality (less than 4%) and morbidity (stroke 3%).

A systematic review and meta-analysis of hybrid aortic arch replacement

BACKGROUND

Evolution in the endovascular era has influenced the management of aortic arch pathologies. Several studies have described the use of a combined endovascular and open surgical approach to the treatment of arch diseases. Hybrid repair of arch pathologies has been considered as a less invasive method, and is therefore an appealing option for high-risk patients who are unsuitable for open repairs. The aim of the present meta-analysis was to assess the efficacy of hybrid techniques in patients with aortic arch pathologies.

METHODS

Extensive electronic literature search was undertaken to identify all articles published up to December 2012 that described hybrid aortic arch repair with intrathoracic supra-aortic branch revascularisation and subsequent stent graft deployment. Eligible studies were divided into two groups: group I included studies on the aortic arch debranching procedure and group II included studies that reported an elephant trunk technique (either "frozen" or stented). Separate meta-analyses were conducted in order to assess technical success, stroke, spinal cord ischemia (SCI), renal failure requiring dialysis, and cardiac and pulmonary complications rate, as well as 30-day/in-hospital mortality.

RESULTS

Forty-six studies were eligible for the present meta-analysis: 26 studies with a total of 956 patients reported aortic arch debranching procedures, and 20 studies with 1,316 patients performed either 'frozen' or stented elephant trunk technique. The pooled estimate for 30-day/in-hospital mortality was 11.9% for the arch debranching group and 9.5% for the elephant trunk group. Cerebrovascular events of any severity were found to have occurred postoperatively at a pooled rate of 7.6% and 6.2%, while irreversible spinal cord injury symptoms were present in a pooled estimate of 3.6% and 5.0% in the arch debranching and elephant trunk group, respectively. Renal failure requiring dialysis occurred at 5.7% and 3.8% in both groups, while cardiac complications rate was 6.0% in the arch debranching cohort and pulmonary complication was 19.7% in the elephant trunk cohort.

CONCLUSIONS

Hybrid arch techniques provide a safe alternative to open repair with acceptable short- and mid-term results. However, stroke and mortality rates remain noteworthy. Future prospective trials that compare open conventional techniques with the hybrid method or the entirely endovascular methods are needed.

Total arch replacement in patients with aortic dissection with an isolated left vertebral artery

BACKGROUND

The presence of an isolated left vertebral artery requires changes in the aortic arch reconstruction techniques and cerebral protection methods in patients with total arch replacement. The best method for surgical repair of the isolated left vertebral artery is controversial. We retrospectively reviewed our experience of total arch replacement in patients with aortic dissection with this vessel anomaly.

METHODS

Between August 2003 and December 2008, 21 patients with aortic dissection (type A dissection, n = 20; type B dissection, n = 1) with an isolated left vertebral artery underwent total arch replacement under hypothermic cardiopulmonary bypass combined with selective cerebral perfusion. Concomitant stented elephant trunk was implanted in 20 patients.

RESULTS

There was no in-hospital death. Injury to the spinal cord occurred in 2 patients with chronic dissection using stented elephant trunk implantation. One had weakness in the left lower extremity, and the other patient had paraparesis: both recovered during the follow-up period. One patient experienced transient neurologic deficit, and acute renal failure was observed in 1 patient: both recovered completely before hospital discharge.

CONCLUSIONS

Acceptable results were obtained in patients with aortic dissection with an isolated left vertebral artery. Although there was no clear evidence that the spinal cord injury was related to the isolated left vertebral artery using stented elephant trunk implantation, the isolated left vertebral artery was constructed as soon as possible in patients with this vessel anomaly.

A case of ascending aortic pseudoaneurysm in a patient with aortic replacement

A 59-year-old man with a history of ascending aorta replacement for an aortic dissection using gelatin-resorcin-formalin glue at age of 50 years presented with paroxysmal nocturnal dyspnea. An echocardiogram showed severe aortic regurgitation associated with aortic root enlargement. Chest computed tomography showed that the ascending aorta was dilated and a pseudoaneurysm was observed around the implanted prosthetic graft. Upon opening the ascending aorta, we found that the posterior wall of the proximal anastomotic portion of the implanted graft was ruptured. After replacement of the aortic root with a composite graft and reconstruction of the orifices of the right and left coronary arteries, total arch replacement by the separated graft technique was performed. The postoperative course was uneventful.

Mid-term results of supraaortic transpositions for extended endovascular repair of aortic arch pathologies

OBJECTIVE

To evaluate mid-term results of supraaortic transpositions for extended endovascular repair of aortic arch pathologies.

METHODS

From October 2002 to July 2006, 27 patients (mean age 72 years) with aortic arch diseases were treated (arch aneurysms n=18, type B dissections n=5, perforating ulcers n=4). Strategy for distal arch disease was autologous sequential transposition of the left carotid artery and of the left subclavian artery in 17 patients. Strategy for entire arch disease was total supraaortic rerouting using a reversed bifurcated prosthesis in 10 patients. Endovascular stent-graft placement was performed metachronously thereafter.

RESULTS

Two in-hospital deaths occurred (myocardial infarction on the day prior to discharge n=1, rupture while waiting for stent-graft placement n=1). At completion angiography, all reconstructions were fully patent. Four patients had small type Ia endoleaks, two of them resolving spontaneously. Mean follow-up is 15 months (1-43 months). Three late deaths occurred (myocardial infarction n=2, sudden unknown death n=1). One-year survival was 83% and 3-year survival was 72%, respectively. Redo stent-graft placement was performed in one patient after 25 months (type III endoleak). The remaining patients had normal CT scans with regular perfusion of the supraaortic branches without any signs of endoleaks.

CONCLUSIONS

Mid-term results of alternative treatment approaches in elderly patients with aortic arch pathologies are satisfying. Extended applications provide safe and effective treatment in patients at high risk for conventional repair.

Aortic Arch Replacement With a Trifurcated Graft

BACKGROUND

The purpose of this study was to review the results of aortic arch replacement using a trifurcated arch graft in conjunction with hypothermic circulatory arrest (HCA) and selective antegrade cerebral perfusion (SCP).

METHODS

One hundred fifty consecutive patients (91 male; mean age, 63 +/- 14 years; range, 20 to 87) had aortic arch replacement using a trifurcated arch graft and HCA/SCP from September 1999 to December 2005. The axillary artery was used for cannulation; a trifurcated graft was sewn to the arch vessels during a short interval of HCA; SCP was utilized through the trifurcation graft during the proximal and distal arch repair, and then the trifurcation graft was sewn to the arch graft. Fifty-five patients had chronic dissection; 48 had atherosclerotic and 29 had degenerative aneurysms; 74 had undergone previous cardiac surgery. Isolated arch reconstruction was undertaken in 38 patients: concomitant procedures included ascending aortic replacement in 74; ascending aorta and root replacement in 21; descending replacement in 4, and coronary artery bypass grafting in 36. An elephant trunk was used in 144, but distal to the left subclavian artery in only 87; in 34, it was distal to the left carotid, in 9, it was between the brachiocephalic and left carotid, and in 18, it was proximal to all arch branches. Mean HCA duration was 31.1 +/- 6.5 minutes; SCP lasted 66.6 +/- 21.0 minutes, at a mean temperature of 15.8 +/- 2.1 degrees C.

RESULTS

Adverse outcome occurred in 13 of 150 patients (8.7%): there were 7 hospital deaths and 6 permanent strokes. Temporary neurologic dysfunction was seen in only 7 patients, and renal failure was transient in 9 patients requiring dialysis.

CONCLUSIONS

The use of a trifurcated arch graft with HCA and SCP is a safe and versatile technique for repair of arch aneurysms.

Total arch replacement: technique of separate reimplantation of epi-aortic vessels

Antegrade selective cerebral perfusion (SCP) with moderate hypothermia is the method of brain protection during aortic arch repair requiring a circulatory arrest longer than 30 min at our institute. It facilitates the total arch replacement using the aortic arch branched graft, and results in acceptable mortality and morbidity for arch aneurysm or dissection.

Surgical outcome of aortic arch repair for patients with Takayasu arteritis

BACKGROUND

Takayasu arteritis can cause segmental dilatation or stenosis of the aorta and its major branches, and surgical treatment of it is still difficult. Our objective was to review late results of aortic arch repair for patients with Takayasu arteritis.

METHODS

Between 1987 and 2003, 21 patients underwent aortic arch repair under circulatory arrest. Diagnosis was performed by pathologic study of specimens for all patients. Total aortic arch repair was performed in 12 patients with separated branched grafts and in 2 patients with the island technique. Selective cerebral perfusion was used in 12 patients and retrograde cerebral perfusion in 2 patients in this type of surgery. Hemiarch replacement using retrograde cerebral perfusion was performed in 7 patients. Craniocervical vascular stenosis was found in 7 patients and aneurysm in 5 patients. The elephant trunk technique was used in 10 patients. The follow-up period was 6.2 +/- 4.2 years.

RESULTS

There was one hospital death due to renal failure, and two late deaths, both of which were sudden. Late in follow-up, a patient who had undergone hemiarch replacement 12 years previously required total aortic arch repair for dilatation of the distal arch. Three patients required thoracoabdominal aortic repair and one patient descending aortic repair for residual aortic dilatation late in follow-up. Postoperative spinal infarction occurred in one patient who underwent hemiarch replacement.

CONCLUSIONS

Surgical and late outcomes of aortic arch repair under circulatory arrest appear favorable, though late dilatation of the residual aorta is a matter of concern.

Total Aortic Arch Replacement in Patients With Arch Vessel Anomalies

BACKGROUND

The presence of anomalous arch vessels has considerable impact on aortic arch reconstruction techniques and cerebral protection methods when the separated graft technique is adopted to perform total arch replacement. We analyzed our experience of total arch replacement in patients with arch vessel anomalies.

METHODS

Among the 220 patients undergoing total arch replacement at our institution, 21 patients (9.5%) had various arch vessel anomalies. Common brachiocephalic trunk was found in 8 patients (3.6%); an isolated left vertebral artery in 9 (4.1%); aberrant right subclavian artery in 3 (1.4%); and coexistent common brachiocephalic trunk and isolated left vertebral artery in 1 (0.5%). In 4 of the 9 patients with isolated left vertebral artery, preoperative diagnosis was possible with magnetic resonance angiography or three-dimensional computed tomography. In cases with common brachiocephalic trunk, total arch replacement could be performed with the usual techniques after separating the innominate and left common carotid arteries from each other. The isolated left vertebral artery was anastomosed to the left subclavian artery graft in 7 patients and to the native left subclavian artery in 2. In the aberrant right subclavian artery variety, a distal aortic anastomosis was performed distal to the orifice of this anomalous artery. The aberrant vessel was reconstructed on the right side of the trachea and esophagus.

RESULTS

There was no early or in-hospital mortality. No neurologic complication attributable to the arch vessel anomalies was found.

CONCLUSIONS

A precise preoperative diagnosis is very important for the selection of an appropriate surgical strategy in patients with arch vessel anomalies. Magnetic resonance angiography and three-dimensional computed tomography may be useful diagnostic tools in these patients.

Aortic Arch Surgery: Thoracoabdominal Perfusion During Antegrade Cerebral Perfusion May Reduce Postoperative Morbidity

BACKGROUND

This study aimed to assess the results of the introduction of thoracoabdominal perfusion (TAP) in the surgical strategy for aortic arch replacement with cerebral protection.

METHODS

Two hundred two arch procedures performed with moderate hypothermia (22 degrees to 26 degrees C) and antegrade cerebral perfusion (ACP) were the objects of retrospective investigation. Acute type A dissection was the indication in 164 patients, aortic aneurysm in 38. In 80 patients, during ACP, the thoracoabdominal aorta was perfused either in an antegrade fashion through proximal descending aorta endoluminal cannulation (in 62 dissections), or retrograde through femoral artery cannulation with proximal descending aorta endoluminal occlusion (in 18 aneurysms). Hospital mortality and morbidity rates were compared between the two treatments (group A: ACP only, 122 patients; group B: ACP plus TAP, 80 patients) and the underlying aortic disease (dissection/aneurysm) was stratified.

RESULTS

Cerebral perfusion (p = 0.008) and cardiopulmonary bypass times (p = 0.035) were significantly longer in group B. No complication related to the TAP technique was observed in group B. Overall hospital mortality was 12.9%, without significant difference between groups. No differences were found in terms of permanent neurological dysfunction between groups A (9.3%) and B (9.1%; p = 0.58). Group B patients showed lower rates of respiratory failure (18.2% versus 30.5% in group A; p = 0.038), shorter mechanical ventilation times (18.1 +/- 26 hours versus 57.9 +/- 70.1; p < 0.001) and lower incidence of acute renal failure (6.5% versus 18.6%; p = 0.012). Shorter intensive care and hospital stays were observed in group B (p = 0.02).

CONCLUSIONS

The adjunction of TAP to ACP was associated with lower rates of end-organ complications, even in more extensive and time-consuming procedures.

Successful Repair of Iatrogenic Acute Aortic Dissection With Cerebral Malperfusion

We describe the successful treatment of a patient with iatrogenic acute aortic dissection including cerebral malperfusion as a complication of coronary artery surgery. After beginning cardiopulmonary bypass, a retrograde ascending aortic dissection associated with cerebral malperfusion was recognized. Systemic circulation was immediately arrested at 31 degrees C. After aortotomy, hypothermic selective antegrade cerebral perfusion was established. Replacement of the ascending aorta with coronary artery bypass grafting was performed without neurologic complications.