Axillary Artery Perfusion Research Articles

The relationship between false-lumen area ratio and renal replacement therapy after acute aortic dissection repair on bilateral artery cannulation: a cross-sectional study.

Malperfusion poses a serious challenge to organ function in the repair of acute aortic dissection (AAD). The purpose of this study was to explore the segment change of false-lumen area ratio (FLAR; the ratio of the maximal false-lumen area to the total lumen area) in the descending aorta and its relationship with renal replacement therapy (RRT) after total aortic arch (TAA) surgery. A total of 228 patients with AAD who received TAA using perfusion mode right axillary and femur artery cannulation between March 2013 and March 2022 were included in a cross-sectional study. The descending aorta was divided into 3 segments: the descending thoracic aorta (S1), the abdominal aorta above the ostium of the renal artery (S2), and the abdominal aorta between the ostium of the renal artery and the iliac bifurcation (S3). The primary outcomes were postoperative segmental FLAR changes in the descending aorta, which were observed using computed tomography angiography before the patients were discharged from the hospital. The secondary outcomes were RRT and 30-day mortality. The total potencies in the false lumen were 71.1%, 95.2%, and 88.2% in S1, S2, and S3. The postoperative/preoperative ratio of the FLAR was higher in S2 than that in S1 and S3 (S1: 67%±14%; S2: 80%±8%; S3: 57%±12%; all P values <0.001). For the patients undergoing RRT, there was a higher postoperative/preoperative ratio of the FLAR for the S2 segment (85%±7% vs. 79%±8%; P<0.001) and higher mortality (28.9% vs. 7.7%; P<0.001) after AAD repair compared with patients in the no-RRT group. This study demonstrated there was less attenuation of the FLAR on the abdominal aorta above the ostium of the renal artery in the whole descending aorta after AAD repair with intraoperative right axillary and femur artery perfusion mode. The patients needing RRT were associated with less postoperative/preoperative change of the FLAR and worse clinical outcomes.

Impact of the Isolated Cerebral Perfusion Technique for Aortic Arch Aneurysm Repair in Patients with a Shaggy Aorta.

Objective: Total aortic arch replacement (TAR), particularly in individuals with extensive atherosclerotic alterations, especially shaggy aortas, is more crucial and difficult. The objective of this retrospective investigation was to ascertain if patients with shaggy aortas would respond to modified isolated cerebral perfusion (ICP). Materials and Methods: Between 2015 and 2020, nine individuals with shaggy aortas who received treatment for arch aneurysms were examined. Four and five patients, respectively, who had arch replacement with traditional selective cerebral perfusion (SCP) and modified ICP, were evaluated, and their short- and long-term results were compared. Results: There were no appreciable variations in the postoperative results between patients with traditional SCP and those with modified ICP. Following surgery, one patient developed paraparesis, while two individuals with traditional SCP experienced persistent neurological damage. In patients with modified ICP, there were no postoperative neurological or other problems associated to atherosclerosis; nevertheless, one patient experienced stroke 5 months after surgery. Conclusion: Patients with shaggy aorta may not receive enough brain protection from TAR with standard SCP because single axillary artery perfusion can result in nonphysiological flow and atheroma separation. Even in patients with shaggy aortas, TAR with modified ICP is safe, but late-phase severe adverse cerebrovascular events should be taken into account.

Bilateral Axillary Artery Perfusion for Aortic Arch Surgery: Worth the Effort?

Bilateral Axillary Artery Perfusion for Aortic Arch Surgery: Worth the Effort?

Bilateral Axillary Artery Perfusion in Total Arch Replacement

BackgroundThe site of arterial cannulation is an important consideration in the prevention of cerebral infarction after total arch replacement. We compared the outcomes of cannulation of the bilateral axillary artery, the femoral artery, and central cannulation in total arch replacement. MethodsEnrolled were 242 patients, categorized into three groups according to the arterial cannulation site used: bilateral axillary artery group, 124 patients; femoral artery group, 88 patients; central cannulation group, 30 patients. Selective cerebral perfusion was used for brain protection in all patients. Surgical outcomes, including the incidence of postoperative cerebral infarction, were compared between the groups. ResultsCardiopulmonary bypass time and lower-body circulatory arrest time were significantly shorter in the bilateral axillary artery group. Frozen elephant trunk procedure was performed in 54% of the bilateral axillary artery group (P < .001), and concomitant coronary artery bypass graft surgery was performed in 40% of the central cannulation group (P < .01). Hospital mortality in the bilateral axillary artery group was 1.6%, compared with 1.1% in the femoral artery group, and 0% in the central cannulation group (P = .72). The incidence of permanent neurologic deficit was significantly lower in the bilateral axillary artery group (0.8%) than in the central cannulation group (13%; P = .02). Logistic regression analysis indicated that bilateral axillary artery perfusion was a significant factor in the prevention of permanent neurologic deficit (odds ratio 0.10, P = .03). ConclusionsRecent technical advances using bilateral axillary artery perfusion and frozen elephant trunk technique were associated with shortening cardiopulmonary bypass time and prevention of postoperative cerebral infarction in total arch replacement.

Antegrade axillary arterial perfusion in 3D endoscopic minimally-invasive mitral valve surgery.

BackgroundMinimally-invasive (MIS) mitral valve (MV) surgery has become standard therapy in many cardiac surgery centers. While femoral arterial perfusion is the preferred cannulation strategy in MIS mitral valve surgery, retrograde arterial perfusion is known to be associated with an increased risk for cerebral atheroembolism, particularly in atherosclerosis patients. Therefore, antegrade perfusion may be beneficial in such cases. This analysis aimed to compare outcomes of antegrade axillary vs. retrograde femoral perfusion in the MIS mitral valve surgery.MethodsThis analysis includes 50 consecutive patients who underwent MIS between 2016 and 2020 using arterial cannulation of right axillary artery (Group A) due to severe aortic arteriosclerosis. Perioperative outcomes of the study group were compared with a historical control group of retrograde femoral perfusion (Group F) which was adjusted for age and gender (n = 50). Primary endpoint of the study was in-hospital mortality and perioperative cerebrovascular events.ResultsPatients in group A had a significantly higher perioperative risk as compared to Group F (EuroSCORE II: 3.9 ± 2.5 vs. 1.6 ± 1.5; p = 0.001; STS-Score: 2.1 ± 1.4 vs. 1.3 ± 0.6; p = 0.023). Cardiopulmonary bypass time (group A: 172 ± 46; group F: 178 ± 51 min; p = 0.627) and duration of surgery (group A: 260 ± 65; group F: 257 ± 69 min; p = 0.870) were similar. However, aortic cross clamp time was significantly shorter in group A as compared to group F (86 ± 20 vs. 111 ± 29 min, p < 0.001). There was no perioperative stroke in either groups. In-hospital mortality was similar in both groups (group A: 1 patient; group F: 0 patients; p = 0.289). In group A, one patient required central aortic repair due to intraoperative aortic dissection. No further cardiovascular events occurred in Group A patients.ConclusionSelective use of antegrade axillary artery perfusion in patients with systemic atherosclerosis shows similar in-hospital outcomes as compared to lower risk patients undergoing retrograde femoral perfusion. Patients with higher perioperative risk and severe atherosclerosis can be safely treated via the minimally invasive approach with antegrade axillary perfusion.

Less Invasive HeartMate 3 Left Ventricular Assist Device Implantation under Deep Hypothermic Circulatory Arrest for Severely Calcified Aorta

Introduction Left ventricular assist devices (LVADs) such as the HeartMate 3 (HM3) are becoming more frequently implanted in those with end-stage heart failure. We present one such patient with prior sternotomies and severely calcified ascending aorta in whom we planned a less invasive LVAD implantation via redo hemi-sternotomy and left thoracotomy with short-term deep hypothermic circulatory arrest (DHCA) to avoid cross-clamping of the aorta. Case Report A 70 year old male with history of two prior cardiac surgeries and heart failure presented in cardiogenic shock requiring temporary mechanical support with Impella CP. He continued to require increasing doses of inotropes and pressors; therefore, he was approved for high risk LVAD placement. A preoperative 4D CT scan revealed severely calcified ascending aorta with only a small area of focal sparing. First, a left anterior thoracotomy in the fifth intercostal space and redo upper hemi-sternotomy was performed. The LVAD outflow graft was positioned through the thoracotomy and brought up to the ascending aorta via the right pleural space, which was opened from the hemi-sternotomy. After initiation of cardiopulmonary bypass, the patient was cooled to 28°C with selective antegrade cerebral perfusion via the right axillary artery and systemic perfusion was temporarily arrested. DHCA was achieved. The LVAD outflow graft was then anastomosed to the aorta after which circulation was restarted and the patient rewarmed. The HM3 LVAD was then implanted in the LV apex and the rest of the operation was completed successfully. Summary Placing an LVAD via thoracotomy has theoretical advantages over a median sternotomy. Surgical trauma is minimized leading to less postoperative bleeding, improved maintenance of the chest stability, earlier recovery, and less cost. Additionally, there might be a reduction in post-operative right heart failure since the pericardium remains intact. Data from the LATERAL study and ELEVATE registry support the safety of this approach. While data support the safety of DHCA in other aortic arch procedures, there are only two case reports of DHCA for LVAD implantation. Our unique case validates the safety of LVAD implantation via thoracotomy and highlights the use of preoperative CT as well as DHCA in placement of an LVAD in a patient with severely calcified ascending aorta.

The application of the single branch-first combined with the mid-arch clamping technique and the embedded anastomosis technique for DeBakey type II aortic dissection

BackgroundPatients with DeBakey type II aortic dissection or ascending aortic aneurysms involving the right innominate artery require hemiarch replacement and placement of a right innominate artery graft. Traditional aortic hemiarch replacement surgery must be performed under right axillary artery cannulation perfusion and moderate or deep hypothermia circulatory arrest. However, the axillary artery perfusion is always associated with left subclavian artery “steal blood”, and it cannot guarantee blood supply to the left cerebral hemisphere in patients with an incomplete circle of Willis, and hypothermia and hypoperfusion cause damage to the brain and spinal cord; therefore, postoperative complications of the nervous system are common. Herein, we present a hemiarch replacement procedure with the use of the single branch-first combined with the mid-arch clamping technique. This procedure can not only reduce the axillary artery incision but also eliminate the need for mid-deep hypothermia and circulatory arrest.Case presentationA 41-year-old male patient underwent surgery with this technique. Computed tomography angiography performed upon admission showed calcified plaques scattered throughout the aorta and showed DeBakey type II aortic dissection involving the right innominate artery, accompanied by cardiac tamponade. The patient underwent aortic root repair, ascending aorta replacement, and hemiarch replacement as well as the placement of a right innominate artery graft. Aortic root anastomosis was performed with the embedded anastomosis technique. There were no postoperative complications. The patient was discharged 11 days after the operation. During more than 3 months of follow-up, there were no cases of aortic valve regurgitation or anastomotic fistula.ConclusionsThe single branch-first combined with the mid-arch clamping technique for the right innominate artery can reduce the axillary artery incision and avoid damage to the body under mid-deep hypothermia and circulatory arrest. The embedded anastomosis technique is easy to perform, results in a limited amount of bleeding and requires almost no extra needling. We believe that these techniques can serve as good alternative strategies for patients with DeBakey type II aortic dissection or ascending aortic aneurysms involving the right innominate artery.

A modified axillo-femoral perfusion for acute type a aortic dissection accompanied with lower limb malperfusion

BackgroundLower limb malperfusion accompanied with acute type A dissection (AAD) is reported to be an independent predictor for mortality. Timely treatment is required. However, staged approach to restore the perfusion of the ischemic leg before aortic repair has a continuously increase risk of aortic rupture. Aortic repair under isolated axillary artery perfusion also has the risk of prolonging leg ischemia. Here we introduce our experience in performing axillo-femoral perfusion, which is supposed to bring benefits for treating lower limb malperfuison.MethodsThirty patients who suffered AAD accompanied by lower limb ischemia enrolled in our study. All patients received aortic repair as soon as possible using the modified axillo-femoral perfusion approach. The cardiopulmonary bypass and cooling started with the right axillary artery perfusion. Then the femoral artery of the ischemic side was exposed and sewn to a graft connected with another inflow cannula. The rectal temperature was about 31 °C when the femoral perfusion started. The perfusion of the ischemic legs preoperative was estimated after the surgery by the clinical signs, the saturation of the distal-limb, and computed tomography scan.ResultsTwenty-eight patients got good perfusion of the lower body after the surgery. Two patients received femoral-femoral artery bypass immediately after surgery because of the thrombosis in the right common iliac artery, without further injury. No peripheral vessels damage occurred, and no compartment fasciotomy or amputation needed. One patient died for the sepsis and the subsequent multi organ failure 28 days postoperative.ConclusionsThe modified axllio-femoral perfusion could restore the lower limbs’ perfusion simultaneously during the aortic surgery without neither delaying dissection repair nor prolonging the ischemic time. It is a simple, but safe and effective technique.

Usefulness of routine use of bilateral axillary artery perfusion in total arch replacement.

To avoid cerebral infarction for aortic arch aneurysm and malperfusion for acute aortic dissection, the site of cannulation during total arch replacement remains important. Recently, we have used bilateral axillary artery perfusion in total arch replacement and in acute aortic dissection. Herein, we report the surgical outcomes. Seventy-eight patients with aortic arch aneurysm and 45 patients with acute aortic dissection were enrolled in this study. During surgery, translocation of the total arch was performed on 67 patients using a 'frozen elephant trunk technique'. In patients with aortic arch aneurysm, there was no postoperative cerebral infarction. New postoperative cerebral infarction was observed in only one patient who underwent acute aortic dissection. Two patients who had aortic arch aneurysm and 2 patients who had acute aortic dissection died at the hospital. Complications related to bilateral axillary perfusion were not observed. The routine use of bilateral axillary artery perfusion in total arch replacement for aortic arch aneurysm to avoid cerebral infarction has the potential to be a useful procedure. It can facilitate the frozen elephant trunk procedure in acute aortic dissection.

A Case of Myonephropathic Metabolic Syndrome from Ischemia in the Right Upper Limb Caused by Right Axillary Artery Perfusion after Total Arch Replacement for Stanford Type A Aortic Dissection

A Case of Myonephropathic Metabolic Syndrome from Ischemia in the Right Upper Limb Caused by Right Axillary Artery Perfusion after Total Arch Replacement for Stanford Type A Aortic Dissection

EP17 IMPACT OF A MODIFIED INTRAOPERATIVE SETTING FOR THE MANAGEMENT OF CIRCULATORY ARREST IN TYPE A ACUTE AORTIC DISSECTION

Background-aim: Despite several recent reports show a trend towards a more extensive arch surgery for patients presenting with type A acute aortic dissection (TA-AAD), in-hospital mortality from IRAD remains high (13–17%). Our study aimed to evaluate the impact of a modified intraoperative setting for the management of circulatory arrest on short and mid-term outcomes in limited repair and complete arch surgery. Methods: From 1997 to 2017, 335 patients with TA-AAD were admitted at our Institution and divided into 3 groups according to the surgical strategy. GROUP-A: retrograde femoral artery perfusion- deep hypothermia (1977–2004;n = 144), GROUP-B: standard anterograde right axillary artery perfusion- moderate hypothermia (2005–2012;n = 102), GROUP-C: right axillary artery with modified monitoring and perfusion lines setting- moderate hypothermia (2013–2017;n = 89). Data was collected and analysed retrospectively. Results: Overall in-hospital mortality: 34.7% in Group-A (mean-age 61.5 ± 12.5years), 13.7% in Group-B (mean-age 63.8 ± 12.8years) and 5.6% in Group-C (mean-age 64.2 ± 11.1years) (p = 0.001). Concerning total-arch replacement, in-hospital mortality was 37% in Group-B vs 0% in Group-C (p = 0.001). Overall 1-year and 5-years survival: 56.3 ± 4.1% and 47.9 ± 4.2% in Group-A, 79.4 ± 4% and 69.6 ± 4.6% in Group-B, 89.5 ± 3.3% and 87.5 ± 3.8% in Group-C (p = 0.001). Group (p = 0.001), CEC-time (p = 0.003), re-exploration (p = 0.001), AKD (p = 0.049) and CVVH (p = 0.007) were predictors for in-hospital mortality in a univariate analysis, re-exploration (HR 4.2) and CVVH (HR 2.1) in a multivariate analysis, Group was a protective factor (HR = 0.25). Conclusions: In our experience current modified approach for the management of circulatory arrest seems to improve overall survival and decrease the risk of in-hospital mortality, showing excellent results especially in total arch replacement.

Simplified surgical approach to improve surgical outcomes in the center with a small volume of acute type A aortic dissection surgery.

BACKGROUND: Despite recent advances in surgical techniques and perioperative management, the surgical mortality of acute type A aortic dissection remains high.OBJECTIVE: In a hospital with few acute type A aortic dissection operations, we retrospectively investigated whether simplified surgical approach could obtain proper surgical outcomes.METHODS: Between October 2007 and December 2016, we performed emergency surgery in 99 patients who had acute type A aortic dissection, including replacement of the hemi-arch in 62 patients (63%) and total arch in 32 patients (32%) and aortic root surgery in 7 patients (7%). Surgical strategy has been simplified over time.RESULTS: We performed right axillary artery perfusion in 61 patients (62%) and antegrade cerebral perfusion in 78 patients (79%). During the last 3 years, in-hospital mortality was decreased to 4% (2/47). Preoperative unresolved shock was an independent predictor of hospital death. Although the patients with total arch replacement or aortic root surgery had a mean significantly long cardiopulmonary bypass or circulatory arrest time, in-hospital mortality or neurologic complications was not increased.CONCLUSIONS: Simplified surgical approach could provide a reasonable surgical outcome in acute type A aortic dissection surgery in a center with a small volume of acute aortic dissection surgery.

Trifurcated graft replacement of the aortic arch: State of the art

To review the contemporary practice in total arch replacement (TAR) by using the trifurcated graft technique. The evolution of the trifurcated graft technique in total arch replacement is described. Axillary artery perfusion with antegrade cerebral perfusion (ACP) is routinely performed, with systemic deep hypothermia based on the anticipated interval of lower body ischemia. Cerebral oxygen saturation is monitored and bilateral ACP (BACP) is performed if the adequacy of collateral circulation is questioned. Potential advantages and disadvantages of unilateral ACP (UACP) vs BACP are discussed. The advantage of the trifurcated graft technique in TAR is that it facilitates the creation of an "elephant trunk" in the proximal arch, making the operation technically easier and avoiding the risk of recurrent laryngeal nerve injury. The technique is also versatile in a variety of aortic arch anatomies and pathologies, while enabling continuous ACP without hypothermic circulatory arrest for cerebral protection. UACP during TAR is acceptable for shorter intervals (<30-40 minutes) if combined with moderate hypothermia. BACP should be considered for prolonged ACP interval or if left cerebral oxygenation is inadequate during UACP. The trifurcated graft technique is a versatile method in TAR that can be applied to a diverse range of aortic anatomies, pathologies and hybrid arch procedures, with concomitant or staged endovascular options. UACP or BACP and lower body ischemia can be performed without adding significant complexity to the procedure, while conferring maximal cerebral, spinal, and lower body protection.

Operative techniques in patients with type A dissection complicated by cerebral malperfusion.

Early mortality and morbidity after surgical treatment for acute type A aortic dissection (AAAD) has remained high over the last decades despite technical improvements and is still in the range of 10–30% [1–6]. The most important risk factor for this still high early mortality is the preoperative status of the patients [4, 7]. Especially end-organ malperfusion contributes significantly to perioperative death and is present in approximately one-third of all patients with acute aortic dissection [3, 7–9]. Coronary, cerebral, visceral and lower extremity malperfusion syndromes are most often associated with type A dissection. A significant surgical dilemma is the treatment of AAAD patients with preoperative cerebral malperfusion [7]. Intimal tears in the proximal aorta often up to 37% [10] result in the involvement of the supra-aortic branches. Consequently, the impaired flow in the brainsupplying arteries is, besides coronary arteries, the most frequent form of malperfusion [7]. The reported incidence of neurological deficit before surgery in AAAD varies between 14% [7] and 20% [11]. The general surgical strategy in AAAD patients is directed towards (i) cannulation and perfusion of the true lumen, (ii) perfusion of all body regions intraoperatively, (iii) a certain degree of hypothermia, (iv) avoiding aortic cross-clamp during distal repair (open distal anastomosis), (v) avoiding changing arterial cannulation site and uncertain de-airing manoeuvres when resuming total body perfusion after distal aortic repair and (vi) unrestricted global perfusion postoperatively. To develop an individual surgical plan for those patients with supra-aortic malperfusion, preoperative assessment of the extent of dissection and type of malperfusion is of utmost importance. This assessment is usually done with computed tomography angiography (CTA) preoperatively, which translates to only a few minutes of delay on the way to the operating theatre and is just as important for the surgical outcome as surgical experience [6, 12]. Malperfusion can be further validated intraoperatively by using transoesophageal echocardiography (TEE), orbital Doppler and near-infrared spectroscopy (NIRS) [9]. One has to keep in mind, however, that NIRS does not provide information in the basilar artery region [9]. There is an ongoing debate about the best surgical strategy for AAAD in general and even more for the high-risk subgroup of patients with cerebral malperfusion [9]. Despite a consensus that the true lumen of the arterial system should be cannulated [13], the approaches vary considerably. This lack of evidence to enable any recommendations for the choice of surgical methods is related to the fact that randomized studies in AAAD (with wide variations of pathologies) are very unlikely to be performed. Even though a meta-analysis of 14 papers between axillary artery and femoral artery perfusion has shown that axillary arterial perfusion had a significantly lower complication rate [14], routes that are currently advocated for AAAD include subclavian (right and left) cannulation, common carotid artery (right and left) cannulation [15, 16], cannulation of the innominate artery, peripheral cannulation of a non-dissected artery (femoral), ascending aortic cannulation (Fig. 1) [17] or apex of the left ventricle (transapical). There is also no agreement about optimal protection (e.g. temperature) during circulatory arrest; however, even the best method of protection would be useless if the cerebral perfusion and other end-organ perfusion have not been restored during cardiopulmonary bypass (CPB) and aortic repair. In this ‘Great Debate’, different approaches are being described and the rationale for doing so is explained by world-known experts in this field. Special emphasis will be placed on common carotid, subclavian and innominate artery cannulation for antegrade cerebral perfusion (ACP). The rationale of retrograde cerebral perfusion (RCP) during selective cerebral perfusion is also described.

Right axillary and femoral artery perfusion with mild hypothermia for aortic arch replacement.

ObjectivesAortic arch replacement is associated with increased mortality and morbidity especially in acute type-A aortic dissection. Although hypothermic circulatory arrest with selective antegrade cerebral perfusion has been widely used because of its excellent cerebral protection, its optimal perfusion characteristics are unknown. The present study investigates clinical results obtained after perfusion method modification and temperature management during cardiopulmonary bypass (CPB).MethodsBetween July 2010 and August 2012, 16 consecutive adult patients (mean age 50.0 yr ± 14.1 yr, range 25 yr to 73 yr, 12 males, 4 females) who presented with acute Stanford type-A aortic dissection underwent aortic arch replacement (total arch, n = 11; hemiarch, n = 5) under mild hypothermia (31.1°C ± 1.5°C) with right axillary and femoral artery perfusion.ResultsThe mean CPB time was 201 min ± 53 min, and the mean myocardial ischemic time was 140 min ± 42 min. The mean selective cerebral perfusion time was 80 min ± 16 min, and the mean lower-body circulatory arrest time was 20 min ± 13 min. No patient death occurred within 30 post-operative days. The following details were observed: new post-operative permanent neurologic deficit in 1 patient (6.3%), temporary neurologic deficit in 2 patients (12.5%), acute renal dysfunction (creatinine level > 230 umol/L) in 3 patients (18.8%) and mechanical ventilation > 72 h in 5 patients (31.2%).ConclusionsAortic arch replacement for acute type-A aortic dissection under mild hypothermia with right axillary and femoral artery perfusion could be safely performed in the patient cohort.

Efficacy of right axillary artery perfusion for antegrade cerebral perfusion in open total arch repair

Right axillary artery (RAxA) perfusion was introduced for selective antegrade cerebral perfusion in total aortic arch repair to prevent cerebral embolism derived from arterial cannulation. However, the strategic benefits and long-term results regarding the cannulation site remain controversial. We retrospectively compared the outcomes between propensity score-matched patients with and without using RAxA cannulation. Between 2006 and 2012, 260 consecutive patients underwent total arch repair with antegrade cerebral perfusion and moderate hypothermia at a single institution. RAxA cannulation was added in 142 patients (54.6%), and 70 propensity score-matched pairs were obtained. There were no significant differences in 30-day (2.9% [2 of 70] vs 5.7% [4 of 70]; P = .415 and in-hospital death (5.7% [4 of 70] vs 5.7% [4 of 70]; P = 1.000) between matched pairs. Although there was no significant difference in the occurrence of postoperative stroke (8.6% [6 of 70] vs 8.6% [6 of 70]; P = 1.000), the new rate of new occurrence of postoperative paraparesis was lower in patients with RAxA perfusion (0% [0 of 70] vs 4.3% [3 of 70]; P = .067). With a mean follow-up period of 1057 ± 686 days, the overall 5-year survival was 90.6% and was 89.6% for patients with RAxA perfusion. Thee difference in survival between patients with and without RAxA perfusion was not significant. RAxA perfusion is a useful option for total aortic arch repair, and the midterm outcomes were satisfactory. However, RAxA perfusion did not completely prevent stroke in patients with an atherothrombotic aorta.

PP-356 A Rare Cause of Pulmonary Hypertension: Distal Pulmonary Artery Stenosis Due To Takayasu Arteritis

A B S T R A C T S maximum diameter of 7.5 cm and patent lumen being 4.85 cms. Eccentric thrombus is seen in the arch. Fusiform aneurysm of infrarenal aorta and bilateral common iliac arteries (Rt > Left).In April 2011 Patient underwent subclavian carotid shunt with 8 mm ring graft under GA. Patient underwent aortic arch aneurysm repair with 24 mm Dacron graft under TCA and antegrade axillary artery perfusion after 2 days. An elephant trunk of about 5 cms was constructed at the time of surgery. MDCT Aortogram 11/12/2012 Residual aneurysm sac arising from the distal arch and proximal descending thoracic aorta has increased in diameter from 67 mm to 82 mmSI dimension of the aneurysm in 98 mm,and it projects inferiorly into the aortopulmonary window. Infra renal abdominal aorta shows fusiform dilatation to 45 mm,increased from 37 mm in previous scanImpression: Increasing size of aortic arch residual aneurysm sac.Increasing size of fusiform infrarenal abdominal aortic aneurysm. Underwent Aortic arch and proximal thoracic aneurysm stenting with a valiant thoracic stent graft 32*200 mm on 21/12/2012. Uneventful post op period. Follow up MDCT Aortogram in Dec 2012,Feb 2013,March and June showed residual aneurysm thrombus noted remains status quo.Stent graft noted in situ.No evidence or stent occlusion or thombus within the graft.

Extracorporeal Membrane Oxygenation with Direct Axillary Artery Perfusion

Extracorporeal membrane oxygenation can be done through several cannulation sites. Axillary artery cannulation is commonly performed through a Dacron graft sutured in an end-to-side fashion to the axillary artery. Direct cannulation of the axillary artery appears a reliable technique with low rate of complications. We report our experience in 16 patients using the direct cannulation technique.

Aortic Valve Replacement in a Porcelain Aorta Using Endo Balloon Occlusion

Aortic valve surgery carries increased risks in patients with an extensively calcified aorta. We describe a technique in which we maintain systemic perfusion via bilateral axillary artery perfusion in conjunction with endoaortic balloon occlusion, and limit the circulatory arrest time.

Axillary Artery Cannulation in Surgery for Acute or Subacute Ascending Aortic Dissections

Perfusion through the right axillary artery is an alternative to aortic or femoral artery cannulation during surgery for ascending aortic dissections. The results of this strategy, particularly beyond the immediate postoperative period, are not well described. Eighty-three patients (median age, 58 years) with acute or subacute ascending aortic dissection underwent surgical repair with right axillary artery perfusion through an interposition Dacron graft. Sixty-five patients (78%) had DeBakey type I dissections. Procedures performed concomitantly with ascending aortic replacement included root replacement (n = 16; 19%), aortic valve repair or replacement (n = 51; 61%), and coronary artery bypass grafting (n = 13; 16%). Hypothermic circulatory arrest with antegrade cerebral perfusion was used in the majority of patients (n = 60; 72%). We retrospectively studied short-term and midterm outcomes, including survival and complications relating to the axillary cannulation. No patient incurred intraoperative axillary artery injuries or had arm ischemia. Fourteen patients (17%) died in the hospital or within 30 days of surgery, and 9 patients (11%) had strokes. Actuarial survival was 73% +/- 5% at 1 year and 64% +/- 6% at 3 years. Forty-six of the 57 surviving patients could be contacted by telephone; they reported few late complications related to the axillary artery cannulation site. These complications included 1 case each of right-arm weakness and right-arm numbness. Surgical repair of acute aortic dissection with right axillary artery perfusion can be performed safely, with a relatively low risk of stroke and a high probability of midterm survival.