Outcomes of Aortic Arch Replacement Performed Without Circulatory Arrest or Deep Hypothermia

Abstract

Background: Aortic arch replacement using standard techniques, including deep hypothermic circulatory arrest and selective antegrade cerebral perfusion, is still associated with significant mortality and cerebral morbidity. We have previously described the “branch-first” technique that avoids circulatory arrest or profound hypothermia with excellent outcomes. We now describe our clinical experience with a larger cohort of patients as well as follow-up of our earlier results. We also describe a further technical simplification to this technique.

Methods: From 2005 to 2010, 43 patients underwent a “branch-first continuous perfusion” technique for aortic arch replacement. In this technique, arterial perfusion is peripheral, usually by femoral inflow. Disconnection of each arch branch and anastomosis to a perfused trifurcation graft proceeds sequentially from the innominate to the left subclavian artery, with uninterrupted perfusion of the heart and viscera by the peripheral cannula. In the first cohort perfusion to the trifurcation graft was by right axillary cannulation. Since 2009, a modification was introduced such that perfusion is supplied directly by a sidearm on the trifurcation graft. This was used in the last 18 patients of this series. After reconstruction of the debranched arch and ascending aorta, the common stem of the trifurcation graft is anastomosed to the arch graft. In this series, there were 27 males, and mean age was 63 ± 13 years. Fifteen cases (35%) were performed with urgent/emergent priority. Nineteen patients (44%) were operated for aortic dissection, and the remainder for aneurysms. Seven patients (16%) had previously undergone a cardiac surgical procedure.

Results: There were two (4.7%) early mortalities while one patient (2.3%) experienced a permanent stroke. One patient (2%) required mechanical support while three (7%) required hemofiltration for renal support. Extubation was achieved within 24 hours in 21 patients (49%) while 19 (42%) were discharged from the Intensive Care Unit (ICU) within two days. Eight patients (19%) did not require any transfusion of red cells or platelets. Mean follow-up duration was 21 ± 19 months and was 100% complete. At three years, survival was 95 ± 3.2%. No patients required subsequent aortic reoperation during this early follow-up period.

Conclusions: This modified branch-first continuous perfusion technique brings us closer to the goal of arch surgery without cerebral or visceral circulatory arrest and the morbidity of deep hypothermia. Our early experience is encouraging although greater numbers and longer follow-up will reveal the full potential of this approach.

Key Words

Aortic arch - Aortic surgery - Cerebral protection

• References

• 1 Reich DL, Uysal S, Sliwinski M, Ergin MA, Kahn RA, Konstadt SN. , et al. Neuropsychologic outcome after deep hypothermic circulatory arrest in adults. J Thorac Cardiovasc Surg 1999; 117: 156-163 . 10.1016/S0022-5223(99)70481-2
• 2 Matalanis G, Koirala RS, Shi WY, Hayward PA, McCall PR. Branch-first aortic arch replacement with no circulatory arrest or deep hypothermia. J Thorac Cardiovasc Surg 2011; 142: 809-815
• 3 Neri E, Massetti M, Capannini G, Carone E, Tucci E, Diciolla F. , et al. Axillary artery cannulation in type A aortic dissection operations. J Thorac Cardiovasc Surg 1999; 118: 324-329 . 10.1016/S0022-5223(99)70223-0
• 4 Kamiya H, Kallenbach K, Halmer D, Ozsoz M, Ilg K, Lichtenberg A. , et al. Comparison of ascending aorta versus femoral artery cannulation for acute aortic dissection type A. Circulation 2009; 120: S282-286
• 5 Kazui T, Yamashita K, Washiyama N, Terada H, Bashar AH, Suzuki K. , et al. Aortic arch replacement using selective cerebral perfusion. Ann Thorac Surg 2007; 83: S796-798 ; discussion S824–831
• 6 Harrington DK, Fragomeni F, Bonser RS. Cerebral perfusion. Ann Thorac Surg 2007; 83: S799-804 ; discussion S2431.
• 7 Di Eusanio M, Trimarchi S, Patel HJ, Hutchison S, Suzuki T, Peterson MD. , et al. Clinical presentation, management, and short-term outcome of patients with type A acute dissection complicated by mesenteric malperfusion: Observations from the International Registry of Acute Aortic Dissection. J Thorac Cardiovasc Surg 2013; 145: 385-390 e1. 10.1016/j.jtcvs.2012.01.042
• 8 Okada K, Omura A, Kano H, Sakamoto T, Tanaka A, Inoue T. , et al. Recent advancements of total aortic arch replacement. J Thorac Cardiovasc Surg 2012; 144: 139-145 . 10.1016/j.jtcvs.2011.08.039
• 9 Iwasaki H, Satoh H, Ishizaka T, Matsuda H. Outcomes of single-stage total arch replacement via clamshell incision. J Cardiothorac Surg 2011; 6: 114
• 10 Kulik A, Castner CF, Kouchoukos NT. Outcomes after total aortic arch replacement with right axillary artery cannulation and a presewn multibranched graft. Ann Thorac Surg 2011; 92: 889-897 . 10.1016/j.athoracsur.2011.04.067
• 11 Matsuyama S, Tabata M, Shimokawa T, Matsushita A, Fukui T, Takanashi S. Outcomes of total arch replacement with stepwise distal anastomosis technique and modified perfusion strategy. J Thorac Cardiovasc Surg 2012; 143: 1377-1381 . 10.1016/j.jtcvs.2011.07.016
• 12 Tanaka M, Kimura N, Yamaguchi A, Adachi H. In-hospital and long-term results of surgery for acute type A aortic dissection: 243 consecutive patients. Ann Thorac Cardiovasc Surg 2012; 18: 18-23 . 10.5761/atcs.oa.11.01704
• 13 Gega A, Rizzo JA, Johnson MH, Tranquilli M, Farkas EA, Elefteriades JA. Straight deep hypothermic arrest: experience in 394 patients supports its effectiveness as a sole means of brain preservation. Ann Thorac Surg 2007; 84: 759-766 ; discussion 66–67. 10.1016/j.athoracsur.2007.04.107
• 14 Kucuker SA, Ozatik MA, Saritas A, Tasdemir O. Arch repair with unilateral antegrade cerebral perfusion. Eur J Cardiothorac Sur 2005; 27: 638-643 . 10.1016/j.ejcts.2005.01.026
• 15 Svensson LG, Nadolny EM, Kimmel W. Multimodal protocol influence on stroke and neurocognitive deficit prevention after ascending/arch aortic operations. Ann Thorac Surg 2002; 74: 2040-2046 . 10.1016/S0003-4975(02)04023-7
• 16 Sabik JF, Nemeh H, Lytle BW, Blackstone EH, Gillinov AM, Rajeswaran J. , et al. Cannulation of the axillary artery with a side graft reduces morbidity. Ann Thorac Surg 2004; 77: 1315-1320 . 10.1016/j.athoracsur.2003.08.056
• 17 Yilik L, Emrecan B, Kestelli M, Ozsoyler I, Lafci B, Yakut N. , et al. Direct versus side-graft cannulation of the right axillary artery for antegrade cerebral perfusion. Texas Heart Inst J 2006; 33: 310-315
• 18 Ergin MA, Uysal S, Reich DL, Apaydin A, Lansman SL, McCullough JN. , et al. Temporary neurological dysfunction after deep hypothermic circulatory arrest: A clinical marker of long-term functional deficit. Ann Thorac Surg 1999; 67: 1887-1890 ; discussion 91–94. 10.1016/S0003-4975(99)00432-4
• 19 Krahenbuhl ES, Immer FF, Stalder M, Englberger L, Eckstein FS, Carrel TP. Temporary neurological dysfunction after surgery of the thoracic aorta: A predictor of poor outcome and impaired quality of life. Eur J Cardiothorac Surg 2008; 33: 1025-1029 . 10.1016/j.ejcts.2008.01.058
• 20 Busto R, Dietrich WD, Globus MY, Valdes I, Scheinberg P, Ginsberg MD. Small differences in intraischemic brain temperature critically determine the extent of ischemic neuronal injury. J Cereb Blood Flow Metab 1987; 7: 729-738 . 10.1038/jcbfm.1987.127
• 21 Greeley WJ, Ungerleider RM, Smith LR, Reves JG. The effects of deep hypothermic cardiopulmonary bypass and total circulatory arrest on cerebral blood flow in infants and children. J Thorac Cardiovasc Surg 1989; 7: 737-745
• 22 Neri E, Sassi C, Barabesi L, Massetti M, Pula G, Buklas D. , et al. Cerebral autoregulation after hypothermic circulatory arrest in operations on the aortic arch. Ann Thorac Surg 2004; 77: 72-79 ; discussion 9–80. 10.1016/S0003-4975(03)01505-4
• 23 Mault JR, Ohtake S, Klingensmith ME, Heinle JS, Greeley WJ, Ungerleider RM. Cerebral metabolism and circulatory arrest: Effects of duration and strategies for protection. Ann Thorac Surg 1993; 55: 57-63 ; discussion 4.
• 24 Gordan ML, Kellermann K, Blobner M, Nollert G, Kochs EF, Jungwirth B. Fast rewarming after deep hypothermic circulatory arrest in rats impairs histologic outcome and increases NFkappaB expression in the brain. Perfusion 2010; 25: 349-354
• 25 Enomoto S, Hindman BJ, Dexter F, Smith T, Cutkomp J. Rapid rewarming causes an increase in the cerebral metabolic rate for oxygen that is temporarily unmatched by cerebral blood flow. A study during cardiopulmonary bypass in rabbits. Anesthesiology 1996; 84: 1392-1400 . 10.1097/00000542-199606000-00016
• 26 Bavaria JE, Woo YJ, Hall RA, Wahl PM, Acker MA, Gardner TJ. Circulatory management with retrograde cerebral perfusion for acute type A aortic dissection. Circulation 1996; 94: II173-76
• 27 Bachet J, Guilmet D, Goudot B, Dreyfus GD, Delentdecker P, Brodaty D. , et al. Antegrade cerebral perfusion with cold blood: A 13-year experience. Ann Thorac Surg 1999; 67: 1874-1878 ; discussion 9194. 10.1016/S0003-4975(99)00411-7
• 28 Zierer A, El-Sayed Ahmad A, Papadopoulos N, Moritz A, Diegeler A, Urbanski PP. Selective antegrade cerebral perfusion and mild (28 degrees C-30 degrees C) systemic hypothermic circulatory arrest for aortic arch replacement: Results from 1002 patients. J Thorac Cardiovasc Surg 2012; 144: 1042-1049 . 10.1016/j.jtcvs.2012.07.063
• 29 Matalanis G, Hata M, Buxton BF. A retrospective comparative study of deep hypothermic circulatory arrest, retrograde, and antegrade cerebral perfusion in aortic arch surgery. Ann Thorac Cardiovasc Surg 2003; 9: 174-179