Integrated Total Arch Replacement Using Selective Cerebral Perfusion: A 6-Year Experience

Mortality and complications following total aortic arch replacement: 14 years' experience

BACKGROUND

Open total arch replacement is one of the most challenging procedures in cardiothoracic surgery and is the gold standard treatment for aortic arch pathology. Total arch replacement is associated with high rates of mortality and neurological morbidity. Using 14 years of data, we studied postoperative, in-hospital mortality, major complications, and examined associated risk factors.

MATERIALS AND METHOD

Medical records of patients who underwent open, total arch replacement surgery at Siriraj Hospital from 2006 to December 2019 were reviewed. Demographic data, clinical factors, preoperative status, intraoperative data, and postoperative data were analyzed.

RESULT

A total of 330 patients were included and 36 (10.9%) died in the hospital. More than one concomitant operation (odds ratio (OR) 5.16, p < 0.001) and emergency operation (OR 3.45, p = 0.003) were risk factors for in-hospital mortality. Major postoperative morbidity occurred in 124 (37.7%) patients (124 of 329). Emergency operation (OR 2.88, p <0.001), preoperative creatinine clearance < 60 ml/ min/ 1.73 m² (OR 2.04, p = 0.004), and aortic cross-clamp time > 180 min (OR 1.75, p = 0.022) were risk factors for major postsurgical complications.

CONCLUSION

In-hospital mortality after total arch replacement was 10.9% compared to international reports. Emergency operation was a major risk factor for both mortality and major complications. More than one concomitant operation, especially coronary artery bypass graft, more than doubled the risk of major complications.

Hypothermia for aortic surgery

Hypothermic circulatory arrest has been used during aortic arch repairs with acceptable neurologic outcomes. Through the years, we have studied the effects of deep hypothermia on brain metabolism and perfusion both in a pig model and in surgical patients. Hypothermic circulatory arrest has also been used as a method of organ protection in the repair of thoracoabdominal aortic aneurysms. We summarize the clinical and laboratory studies to support the routine use of hypothermic circulatory arrest in clinical practice.

Total arch replacement in a patient with an unusual vascular anatomy

A 69-year-old man with a history of infectious abdominal aortic aneurysm, which had resulted in removal of the infrarenal abdominal aorta and bilateral axillofemoral bypass 9 years previously, underwent total arch replacement for an aortic arch aneurysm. The patient had the interrupted abdominal aorta and highly atherosclerotic proximal aorta, which precluded the possibility of endovascular stent grafting in combination with arch vessel debranching technique. Therefore, open arch repair was the only treatment option. The operation was successful with his axillofemoral bypass graft being exposed and used for arterial inflow during cardiopulmonary bypass, including integrated selective antegrade cerebral perfusion.

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.

Brief review on systematic hypothermia for the protection of central nervous system during aortic arch surgery: a double-sword tool?

Antegrade selective cerebral perfusion in conjunction with hypothermia attenuate postoperative neurological injury, which in turn still remains the main cause of mortality and morbidity following aortic arch surgery. Hypothermic circulatory arrest however could be a useful tool during arch surgery, surgery for chronic thromboembolic disease, air on the arterial line during CPB, during cavotomy for extraction of renal cell carcinoma with level IV extension, or when dealing with difficult trauma to the SVC or IVC. Cerebral protective effects with hypothermic procedures including inhibition of neuron excitation, and discharge of excitable amino acids, and thereby, prevention of an increase in intercellular calcium ions, hyperoxidation of lipids in cell membranes, and free radical production.The authors are briefly discussing the fundamental principles of using hypothermia as an adjunct tool of the cardiothoracic surgeon's practice. The relationship between temperature, flow, metabolic requirements and adverse effects is addressed.

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

OBJECTIVES

The present study was undertaken to identify risk factors for permanent neurological dysfunction (PND) and in-hospital mortality after total aortic arch replacement (TAR) with separate arch vessel grafting using selective cerebral perfusion (SCP) and hypothermic circulatory arrest.

METHODS

Between 1998 and 2008, we preformed a TAR on 143 consecutive patients in two centers by identical methods. Of these, 19 (13.3%) were emergency operations, and 46 (32.2%) were open stent-graft placements. Statistical analysis was performed to determine risk factors for PND and mortality, and furthermore, the survival rate was analyzed.

RESULTS

The in-hospital mortality rate was 4.9%, with chronic renal failure (p = 0.0013, odds ratio 10.0) as a significant risk factor. Nine patients (6.3%) had PND, with significant risk factors identified as (1) the presence of an old cerebral or silent lacunar infarction on preoperative imaging methods (p = 0.0458, odds ratio 8.0) and (2) duration of SCP (p = 0.0026, odds ratio 1.036). Long-term survival was the same in patients with or without PND.

CONCLUSION

The enhanced vulnerability of the brain in patients with a pre-existing old cerebral infarction or silent lacunar infarction is reflected by a high incidence of PND. Chronic renal failure had an impact on in-hospital mortality.

Central Nervous System Protection in Cardiac Surgery

Neurological dysfunction and stroke following cardiac surgery and thoracic surgery requiring hypothermic circulatory arrest is a well-defined problem. The original studies in CABG patients identified risk factors, such as prior stroke and lower educational level. There is older evidence suggesting that higher perfusion pressures during cardiopulmonary bypass are helpful. Hyperthermia during rewarming on cardiopulmonary bypass and postoperative hyperthermia have been associated with adverse cognitive outcomes. Glucose management intraoperatively remains controversial, but most now advocate for moderate glucose control using insulin, if required. The subset of patients having thoracic aortic surgery requiring periods of aortic discontinuity are particularly problematic. A cerebral protection strategy should be determined, and this may include hypothermic circulatory arrest, selective cerebral perfusion, or retrograde cerebral perfusion. All of these techniques have been associated with good surgical outcomes, but there is little information on cognitive outcomes of thoracic aortic surgery.

Hypothermie in der Herzchirurgie

Since the beginning of the era of cardiac surgery hypothermia remains a mainstay in perioperative management. This role is increasingly being questioned because of many disadvantages and the lack of evidence of advantages. Using modern techniques of perfusion and myocardial protection as well as improved surgical techniques the results with normothermia seem to be comparable. The importance of hypothermia in present day cardiac surgery is discussed with respect to myocardial and cerebral protection.