Factors influencing permanent neurologic dysfunction and mortality after total arch replacement with separate arch vessel grafting using selective cerebral perfusion

Evolving Surgical Techniques and Improving Outcomes for Aortic Arch Surgery in Canada

Background

To explore evolving surgical techniques and outcomes for aortic arch surgery.

Methods

A total of 2435 consecutive patients underwent aortic arch repair with hypothermic circulatory arrest between 2008 and 2018 in 12 institutions across Canada. Trends in patient characteristics, surgical techniques, and in-hospital outcomes, including major morbidity or mortality, were examined.

Results

From 2008 to 2018, the age of patients (62.3 ± 13.2 years) and the proportion of women (30.2%) undergoing arch surgery did not change significantly. Aortic diameters at operation decreased (2008: 58 ± 13 mm; 2018: 53 ± 11 mm; P < 0.01). Surgeons performed more valve-sparing root replacements (2008: 0%; 2018: 15%; P < 0.001) and fewer Bentall procedures (2008: 27%; 2018: 20%; P < 0.01). Total arch replacement rates were similar (P = 0.18); however, elephant trunk (2008: 9.5%; 2018: 19%; P < 0.001) and frozen elephant trunk (2008: 3.1%; 2018: 15%; P < 0.001) repair rates have increased. Over time, higher nadir temperatures (2008: 18 [17-21]°C; 2018: 25 [23-28]°C; P < 0.001), and more frequent antegrade cerebral perfusion (2008: 61%; 2018: 83%; P < 0.001) were used. For elective cases, in-hospital mortality rates declined (2008: 6.8%; 2018: 1.2%; P = < 0.01), as did major morbidity or mortality (2008: 24%; 2018: 13%; P < 0.001) and transfusion rates (2008: 61%; 2018: 41%; P < 0.001), but stroke rates remained constant (2008: 6.8%; 2018: 5.3%; P = 0.12). Outcomes remained the same over time for urgent or emergent cases.

Conclusions

Outcomes have improved over the past decade in Canada for elective aortic arch surgery, in the context of operating on smaller aortas, and more frequent use of moderate hypothermia and antegrade cerebral perfusion. Further research is needed to improve stroke rates and outcomes in the emergency setting.

Total arch repair with frozen elephant trunk using the “zone 0 arch repair” strategy for type A acute aortic dissection

OBJECTIVE

The aim of this study was to investigate the effect of frozen elephant trunk deployment from the zone 0 aorta to the descending aorta on early and midterm postoperative results in patients with acute type A aortic dissection.

METHODS

Between October 2014 and April 2018, 108 patients underwent a combined strategy of frozen elephant trunk deployment, ascending aortic replacement, and arch vessel reconstruction ("zone 0 arch repair" strategy) for acute type A aortic dissection (excluding DeBakey type II). Of the 108 patients, 32 (29.6%) had primary tears of the aortic arch or descending aorta.

RESULTS

The 30-day mortality rate was 2.8% (3 patients), and in-hospital mortality rate was 6.5% (7 patients). New-onset permanent neurologic dysfunction and spinal cord injury occurred in 3.7% and 0% of patients, respectively. Five of the 101 survivors underwent thoracic endovascular aortic repair during hospitalization (2 for rapid false lumen enlargement; 3 for true lumen stenosis). The overall survival was 89.8%, 88.1%, and 88.1% at 1, 2, and 3 years, respectively. The cumulative incidence of distal aortic reintervention was 5.8%, 9.1%, and 9.1% at 1, 2, and 3 years, respectively. Two patients underwent thoracic endovascular aortic repair for distal aortic enlargement after discharge.

CONCLUSIONS

The use of the "zone 0 arch repair" strategy can eliminate the need for invasive aortic arch resection. It also eliminates the false lumen and produces satisfactory early and midterm postoperative results. Therefore, it can be an alternative to hemiarch and total arch replacements, which are based on a conventional "tear-oriented resection" strategy.

Early and mid-term outcomes of the aortic arch surgery: experience from the low-volume centre

Aim

The aim of this retrospective study was to examine the early and mid-term outcomes for patients undergoing elective aortic arch surgery over a 13-years period in the single low-volume centre. Results of aortic arch surgery published in the literature are usually results of high-volume centers, but the majority of institutions have much lower caseload.

Methods

From January 1999 to March 2013 total of 353 surgeries on thoracic aorta were performed in our institution. Only 30 procedures (8.5%) were elective aortic arch surgeries. This group of patients was analyzed.

Results

Deep hypothermia alone and hypothermia with ortograde cerebral perfusion was used in 7 (23%) and 23 (77%) patients respectively. Mean core temperature was 22°C (17 – 26°C). Cannulation sites was axillary artery or brachiocephalic trunk in 17 (57%), femoral artery in 8 (27%) and ascending aorta or aortic arch in 5 (16%). Mean hypothermic circulatory arrest time was 39 min (15 – 74 min). There was one death due to multiorgan failure; all-cause mortality at 30 days was 3.3%. The frequency of other complications was permanent neurological deficit in 2 (6.7%), temporary neurological deficit in 2 (6.7%) and renal failure requiring hemodialysis in 2 (6.7%) patients. In the follow-up 13 patients died, remaining 16 are still alive.

Conclusion

Despite the lower caseload and technical problems manifested by a higher number of re-operations for bleeding, the all-cause mortality at 30 days as well as mid-term results are comparable with results reported by the high-volume centres.

Outcomes of aortic arch replacement surgery after previous cardiac surgery

BACKGROUND

Aortic arch replacement is a potentially high-risk operation and in the re-operative setting has been found to be a risk factor for poor outcome, yet there is a dearth of published data specifically on this topic. The aim of the study was to review our unit's outcomes in this re-operative setting.

METHOD

Data were collated for all patients who underwent aortic arch replacement surgery after previous cardiac surgery from January 1988 to November 2011. The patients were divided based primarily on elective versus non-elective and also early (≤2005) and late (≥2006) series.

RESULTS

Twenty-seven eligible patients (22 male; median age: 53.0 years; elective: 14, non-elective: 13) were identified. There was a mean period of 14.5 years between the first operation and the subsequent aortic arch replacement. The overall 30-day mortality rate was 22.2% - 0% elective and 46.2% non-elective (P = 0.004). Overall permanent neurological dysfunction was 21.7% - 28.6% elective and 11.1% non-elective (P = 0.463). There were 11 early-series patients and 16 late-series patients. For early-series patients, 90.9% were non-elective versus 18.8% in the late-series patients. The 30-day mortality rate was 54.5% early series versus 0% late series.

CONCLUSION

Aortic arch replacement is high risk in the re-operative setting. These risks are even greater for non-elective procedures. This highlights the need for aggressive first-time surgery to reduce re-operative procedures and good long-term follow-up programmes to allow elective procedures if required.

Arch replacement using antegrade selective cerebral perfusion for shaggy aorta

Background: Embolic stroke during arch replacement is a serious concern in patients with shaggy aorta.

Objective: To evaluate shaggy aorta in patients who received total aortic arch replacement with antegrade selective cerebral perfusion utilizing axillary perfusion.

Method: Between January 2005 and December 2010, 63 patients underwent preoperative contrast-enhanced computed tomography scanning of the aorta to evaluate atheromatous plaque. We analyzed operative data to investigate which factors were associated with outcomes and survival.

Results: Shaggy aorta was found in 34 (54%) patients. There were 3 (5%) cases in the ascending aorta, 26 (41%) in the aortic arch, and 19 (30%) in the descending aorta. Operative mortality occurred in 1 (2%) patient. Although stroke occurred in 2 (3%) shaggy aorta patients, shaggy aorta was not associated with an increased likelihood of stroke ( p = 0.4951). Survival was significantly lower in patients with shaggy descending aorta ( p = 0.0411) and in patients >75-years old ( p = 0.0200); these traits were identified as independent risk factors for late death ( p = 0.0368 and p = 0.0100, respectively).

Conclusion: We concluded that our perfusion technique protects patients with shaggy aorta against embolism, and that the survival is lower in patients with shaggy descending aorta.

Selective cerebral perfusion with 4-branch graft total aortic arch replacement: outcomes in 12 patients

Background

Aortic arch reconstruction is associated with high neurological morbidity. Our purpose is to describe our experience using a 4-branched graft and selective antegrade brain perfusion (SABP) for total aortic arch replacement (TAR).

Methods

We retrospectively reviewed the medical records of 12 patients who received TAR, with or without ascending aorta replacement, with a 4-branched graft for Stanford type A dissection (n = 9) or aortic arch aneurysm (n = 3). In all patients surgery was performed with deep hypothermic circulatory arrest (DHCA) with or without retrograde brain perfusion, and selective antegrade brain perfusion (SABP) via the subclavian artery or axillary artery.

Results

There were 8 males and 4 females with an average age of 63.14 years. Emergent operations were performed in 9 patients with acute type A aortic dissections. Of all 12 patients, 2 deaths occurred and 1 patient experienced lower extremity paraplegia resulting in an in-hospital mortality rate of 16.6% and a permanent neurological deficit rate of 8.3%.

Conclusions

The use of a 4-branched graft, hypothermic circulatory arrest, and SABP is a useful operative method for aortic arch replacement with acceptable morbidity and mortality.