Total Arch Replacement with Hypothermic Circulatory Arrest, Antegrade Cerebral Perfusion and the Y-graft

Clinical outcome of a branch-first approach with a novel continuous whole-brain perfusion strategy for total arch surgery

BACKGROUND

Cerebral protection strategies have been investigated since the introduction of aortic arch surgery and have been modified over the centuries. However, the cerebral protective effects of unilateral and bilateral antegrade cerebral perfusion are similar, with opportunities for further improvement.

METHODS

A total of 30 patients who underwent total arch surgery were enrolled in this study. Patients were assigned to the novel continuous whole-brain or unilateral antegrade cerebral perfusion group according to the cerebral perfusion technique used. Preoperative clinical data and 1-year postoperative follow-up data were collected and analyzed.

RESULTS

There were no significant differences between the two groups in terms of the incidence of permanent neurological deficit, mortality, or therapeutic efficacy. However, the incidence of temporary neurological dysfunction in the novel whole-brain perfusion group was significantly lower than that in the unilateral antegrade cerebral perfusion group.

CONCLUSIONS

In this study, the branch-first approach with a novel whole-brain perfusion strategy had no obvious disadvantages compared with unilateral antegrade cerebral perfusion in terms of cerebral protection and surgical safety. These findings suggest that this new technique is feasible and has application value for total arch surgery.

Clinical outcomes of mild versus moderate hypothermic circulatory arrest with antegrade cerebral perfusion in adult aortic arch surgery: A systematic review and meta-analysis

OBJECTIVES

In adult aortic arch surgery, moderate hypothermic circulatory arrest (HCA) with selective antegrade cerebral perfusion (SACP) (MoHACP) is widely used, but the application of mild HCA with SACP (MiHACP) is still controversial. This meta-analysis aimed to compare clinical outcomes using MiHACP or MoHACP.

METHODS

Studies comparing outcomes of MiHACP or MoHACP in adult aortic arch surgery were searched from four databases from inception through April 2022. Primary outcomes were postoperative permanent neurological deficit (PND), temporary neurological deficit (TND), and mortality. Secondary outcomes included other common complications. Meta-analysis was conducted using a random-effects model in all cases.

RESULTS

Eleven comparative studies were included, with 1555 patients in MiHACP group and 1499 patients in MoHACP group, and the mean HCA temperature were 29.4°C and 24.8°C, respectively. Postoperative PND, TND, mortality, paraplegia, dialysis, tracheotomy, reexploration for bleeding, and chest tube drainage volume were comparable in the two groups (p > 0.05). Ventilator time, intensive care unit and in-hospital length of stay were shorter in MiHACP group (p < 0.05). Outcomes were also comparable or had some benefits in MiHACP group when subgroup analyses were conducted according to hemiarch or total arch replacement, unilateral or bilateral SACP, HCA time, emergency aortic dissection surgery, and concomitant procedure.

CONCLUSION

The present meta-analysis showed acceptability of MiHACP in adult aortic arch surgery. Results need to be taken with caution as moderate risk of bias and very low quality of evidence were observed in this meta-analysis. Randomized controlled trials are needed for further analysis.

Bentall surgery and total arch repair with debranching of supra-aortic vessels: a case report

Background

The surgical approach to pathologies of the Ascending Thoracic Aorta (ATA) that compromise aortic root and the aortic arch is currently one of the most complex interventions in the spectrum of cardiac surgery, where circulatory arrest with cerebral perfusion plays an important role for Success postoperative and patient survival.

Case presentation

We present the case of a 57-year-old patient with the only history of arterial hypertension and an ATA Aneurysm that compromised segment of the aortic root up to segment 2 of the aortic arch. A successful Bentall surgery was performed, debranching supra-aortic vessels with Total Circulatory Arrest with Deep Hypothermic Cerebral Perfusion-Antegrade Bilateral.

Conclusions

With the advent of new anesthetic and neuroprotection techniques, perioperative imaging protocols, advanced hemodynamic monitoring, and invaluable advances in perfusion and Extracorporeal Circulation with circulatory arrest, they have made this surgical challenge a valuable tool for today’s cardiovascular surgeon.