Lower Body Circulatory Arrest Research Articles

Long-term outcomes of total arch replacement with bilateral antegrade cerebral perfusion using the "arch first" approach.

To report outcomes of total arch replacement (TAR) with hypothermic circulatory arrest and bilateral antegrade cerebral perfusion (bACP) using an "arch first" approach for acute Type A aortic dissection (ATAAD). The "arch first" approach involved revascularization of the aortic arch branch vessels with uninterrupted ACP, before lower body circulatory arrest, while the patient was cooling. This was an observational study of aortic surgeries from 2010 to 2021. All patients who underwent TAR with bACP for ATAAD were included. Short-term and long-term outcomes were reported utilizing descriptive statistics and Kaplan-Meier survival estimation. A total of 215 patients were identified who underwent TAR + bACP for ATAAD. Age was 59.0 [49.0-67.0] years and 35.3% were female. 73 patients (34.0%) underwent a concomitant aortic root replacement, 188 (87.4%) had aortic cannulation, circulatory arrest time was 37.0 [26.0-52.0] minutes, and nadir temperature was 20.8 [19.4-22.5] degrees Celsius. 35 patients (16.3%) had operative mortality (STS definition), 17 (7.9%) had a new stroke, 79 (36.7%) had prolonged mechanical ventilation (>24h), 35 (16.3%) had acute renal failure (by RIFLE criteria), and 128 (59.5%) had blood product transfusions. One-year survival was 77.1%, while 5-years survival was 67.1%. During follow-up, there were 23 (10.7%) reinterventions involving the descending thoracic aorta - either thoracic endovascular aortic repair or open thoracoabdominal aortic replacement. Among patients with ATAAD, short-term postoperative outcomes after TAR + bACP using the "arch first" approach are acceptable. Moreover, this operative strategy may furnish long-term durability, with a reasonably low reintervention rate and satisfactory overall survival.

Meta-analysis: Bilateral and Unilateral Cerebral Perfusion in Type A Dissection.

This meta-analysis compared the outcomes of bilateral cerebral perfusion (BCP) and unilateral cerebral perfusion (UCP) in aortic surgery for acute type A aortic dissection. A systematic literature search identified 12 studies involving 4,547 patients. Pooled odds ratios (OR) with 95% confidence intervals (CI) were calculated to analyze perioperative characteristics, short-term mortality rates, and postoperative neurological complications. No significant differences were found between the BCP and UCP groups in terms of cardiopulmonary bypass time, aortic cross clamp time, lowest body temperature, and lower body circulatory arrest time. Short-term mortality rates (OR [95% CI] = 0.87 [0.64-1.19], p = 0.40) and permanent neurological deficits (OR [95% CI] = 1.01 [0.69-1.47], p = 0.96) were comparable between the groups. However, subgroup analysis of studies exclusively involving total arch replacement showed a lower short-term mortality rate (OR [95% CI] = 0.42 [0.28-0.63], p < 0.01) and permanent neurological deficits (OR [95% CI] = 0.53 [0.30-0.92], p = 0.03) in the BCP group. The BCP group also had a lower rate of temporary neurological deficits (OR [95% CI] = 0.70 [0.53-0.93], p = 0.01), particularly in studies exclusively involving total arch replacement (OR [95% CI] = 0.58 [0.40-0.85], p < 0.01). This meta-analysis suggests that BCP and UCP yield comparable outcomes. However, BCP may be associated with lower short-term mortality rates and reduced incidence of neurological complications, particularly in cases requiring total arch replacement. BCP should be considered as a preferred cerebral perfusion in specific patient populations.

Early outcome of simplified total arch reconstruction under mild hypothermia (30–32 °C) with distal aortic perfusion

ObjectiveWe designed a simplified total arch reconstruction (s-TAR) technique which could be performed under mild hypothermia (30–32 °C) with distal aortic perfusion. This study aimed to compare its efficacy of organ protection with the conventional total arch reconstruction (c-TAR).MethodsWe reviewed the clinical data of 195 patients who had ascending aortic aneurysm with extended aortic arch dilation and underwent simultaneous ascending aorta replacement and TAR procedure between January 2018 and December 2022 in our center. 105 received c-TAR under moderate hypothermia (25–28 °C) with circulatory arrest (c-TAR group); rest 90 received s-TAR under mild hypothermia (30–32 °C) with distal aortic perfusion (s-TAR group).ResultsThe s-TAR group demonstrated shorter CPB time, cross-clamp time and lower body circulatory arrest time compared with the c-TAR group. The 30-day mortality was 2.9% for the c-TAR group and 1.1% for the s-TAR group (P = 0.043). The mean duration of mechanical ventilation was shorter in the s-TAR group. Paraplegia was observed in 4 of 105 patients (3.8%) in the c-TAR group, while no such events were observed in the s-TAR group. The incidence of temporary neurologic dysfunction was significantly higher in the c-TAR group. The incidence of permanent neurologic dysfunction also showed a tendency to be higher in the c-TAR group, without statistical significance. Furthermore, the incidence of reoperation for bleeding were significantly lower in the s-TAR group. The rate of postoperative hepatic dysfunction and all grades of AKI was remarkably lower in the s-TAR group. The 3-year survival rate was 95.6% in the s-TAR group and 91.4% in the c-TAR group.Conclusionss-TAR under mild hypothermia (30–32℃) with distal aortic perfusion is associated with lower mortality and morbidity, offering better neurological and visceral organ protection compared with c-TAR.

Zone 2 arch repair for acute type A dissection: Evolution from arch-first to proximal-first repair.

With growing experience of acute type A aortic dissection repair, Zone 2 arch repair has been advocated. The aim of this study is to compare the outcome between "proximal-first" and "arch-first" Zone 2 repair. From January 2015 to March 2023, 45 patients underwent Zone 2 arch repair out of 208 acute type A aortic dissection repairs: arch-first, N=19, and proximal-first technique, N=26, since January 2021. Indications were aortic arch or descending tear, complex dissection in neck vessels, cerebral malperfusion, or aneurysm of the aortic arch. The lowest bladder temperature was higher in the proximal-first technique (24.9 °C vs 19.7 °C, P<.001). Cardiopulmonary bypass (230 vs 177.5minutes, P<.001), myocardial ischemic (124 vs 91minutes, P<.001), and lower-body circulatory arrest (87 vs 28minutes, P<.001) times were shorter in the proximal-first technique. The arch-first group required more packed red blood cells (arch-first, 2 units vs proximal-first, 0 units, P=.048), platelets (arch-first, 4 units vs proximal-first, 2 units, P=.003), and cryoprecipitates (arch-first, 2 units vs proximal-first, 1 unit, P=.024). Operative mortality and major morbidities were higher in the arch-first group (57.9% vs 11.5%, P=.001). One-year survival was comparable (arch-first, 89.5% ± 7.0% vs proximal-first, 92.0% ± 5.5%, P=.739). Distal intervention was successfully performed in 5 patients (endovascular, N=3, and open repair, N=2). Zone 2 arch repair using the proximal-first technique for acute type A aortic dissection repair yields shorter lower-body ischemic time with a warmer core temperature, resulting in shorter cardiopulmonary bypass time, less blood product use, and fewer morbidities when compared with the arch-first technique.

Simplified total arch reconstruction with a stented graft for extended aortic arch dilation.

Reconstruction of the aortic arch and its three supra-aortic vessels remains a great surgical challenge with postoperative complications. We present a simplified total arch reconstruction with a modified stent graft (s-TAR) and compared its operative outcomes with conventional total arch replacement (c-TAR). This retrospective analysis of prospectively collected data from all consecutive patients who had ascending aortic aneurysm with extended aortic arch dilation and underwent simultaneous ascending aorta replacement and aortic arch reconstruction with the s-TAR or c-TAR between 2018 and 2021. The indication for intervention was maximum diameter of ascending aorta >55 mm and aortic arch in zone II >35 mm. A total of 84 patients were analyzed: 43 in the s-TAR group and 41 in the c-TAR group. No inter-group differences were found for sex, age, comorbidities, or EuroSCORE II results. All patients were successfully treated with s-TAR or c-TAR, and none died intraoperatively. Cardiopulmonary bypass, selective cerebral perfusion, and lower-body circulatory arrest time were significantly shorter in the s-TAR group, which also had a lower incidence of prolonged ventilation and transient neurologic dysfunction. No patient in either group experienced permanent neurologic dysfunction. The incidence of recurrent laryngeal nerve injury and paraplegia was markedly increased in the c-TAR group; however, no such events were observed in the s-TAR group. Both perioperative blood loss and the incidence of reoperation for bleeding were significantly lower in the s-TAR group. The in-hospital mortality rate was 0% in the s-TAR group and 4.9% in the c-TAR group. The s-TAR group had significantly shorter intensive care unit (ICU) stay and lower total hospitalization costs. The s-TAR technique is a safe and effective alternative for total arch reconstruction with shorter operation time, lower rate of postoperative complications and lower total hospitalization costs compared with c-TAR.

Lower Body Perfusion Reduces the Morbidity of Postoperative Acute Kidney Injury in Type A Dissection: A Propensity-Matched Analysis.

Lower body perfusion (LBP) is a technique used to provide blood perfusion to distal organs and spinal cord during circulatory arrest. However, the effect of LBP on the prognosis of aortic arch surgery, especially on postoperative renal function, remains unclear. A total of 304 patients with acute type A aortic dissection who underwent total aortic arch replacement combined with frozen elephant trunk implantation between May 2016 and December 2021 were retrospectively analyzed. The patients were divided into LBP group (group L, n=85) and non-LBP group (group NL, n=219). Routine lower body circulatory arrest was applied during operation in group NL, and antegrade LBP combined was applied during operation in group L. Perioperative data were recorded. Propensity score matching was used for statistical analysis. After propensity score matching, 85 pairs of patients were successfully matched. Two groups significantly differed in circulatory arrest time (six minutes vs. 30 minutes, P=0.000), cross-clamping time (101 minutes vs. 92 minutes, P=0.010), minimum nasopharyngeal temperature (29.4ºC vs. 27.2ºC, P=0.000), and highest lactate value during cardiopulmonary bypass (2.3 μmol/L vs. 4.1 μmol/L, P=0.000). Considering the postoperative indicators, the drainage volume (450 mL vs. 775 mL, P=0.000) and the incidence of level I acute kidney injury (23.5% vs. 32%, P=0.046) in group L was lower than those in group NL. LBP resulted as a safe and feasible approach in aortic arch surgery, as it could significantly shorten the circulatory arrest time, which might reduce the incidence of postoperative level I acute kidney injury.

Challenging Paradigm Limits of Retrograde Cerebral Perfusion During Lower Body Circulatory Arrest

IntroductionRetrograde cerebral perfusion (RCP) is a safe and effective technique to augment cerebral protection during lower body circulatory arrest in patients undergoing elective hemiarch replacement. However, recommendations guiding optimal temperature, flow rate, and perfusion pressure are outdated and potentially overly limiting. We report our experience using RCP for elective hemiarch replacement with parameters that challenge the currently accepted paradigm. MethodsThis was a single-center, retrospective analysis of 319 adult patients who underwent elective hemiarch replacement between February 2010 and 2021 using hypothermic lower body circulatory arrest with RCP alone, RCP followed by antegrade cerebral perfusion (ACP), or ACP alone. Flow rates were adjusted to maintain cerebral perfusion pressure between 30 and 50 mm Hg for RCP and between 40 and 60 mm Hg for ACP. ResultsRCP was used in 22.6% (n = 72) of cases, whereas ACP alone was performed in 77.4% (n = 247) of cases. Baseline patient characteristics were similar between groups. Patients undergoing RCP demonstrated shorter cross-clamp time (97.0 min versus 100.0 min, P = 0.034) and shorter lower body circulatory arrest time (7.0 min versus 10.0 min, P < 0.0001) compared with ACP alone. Nadir bladder temperature was equivalent between groups (27.3°C versus 27.5°C, P = 0.752). There were no significant differences in postoperative complications, neurologic outcomes, or mortality. ConclusionsModerate hypothermic lower body circulatory arrest combined with RCP at target perfusion pressures of 30-50 mm Hg in patients undergoing elective hemiarch replacement results in equivalent neurologic outcomes and overall morbidity to cases using ACP alone. These results challenge the currently accepted paradigm for RCP, which typically uses deep hypothermia while keeping perfusion pressures below 25 mm Hg.

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.

Postoperative results of the in situ fenestrated open stent technique for acute aortic dissection type A

ObjectiveTotal arch replacement is commonly used for acute aortic dissection type A at some facilities, especially since open stent grafting became commercially available in Japan. Left subclavian artery (LSCA) reconstruction involves deep view manipulation, is difficult to expose and anastomose, and involves the risk of complications and surrounding vascular injury.MethodsWe evaluated 137 patients (mean age 73.8 ± 15.6 years) who underwent total arch replacement for acute aortic dissection type A, at our hospital between September 2014 and March 2022, and divided them into two groups: 70 patients for total arch replacement with fenestrated open stent technique (FeneOS), and 67 for conventional total arch replacement with the reconstruction of three-branch cerebral vessels. We performed FeneOS by deploying the graft from the entry of the left subclavian artery into the descending aorta and fenestrating the LSCA side of the stenting portion. The four-branched artificial vessel was then anastomosed between the left common carotid artery and LSCA.ResultsThe surgical results of FeneOS were satisfactory and enabled significant reductions in operative time, selective cerebral perfusion time, cardiopulmonary bypass time, and lower body circulatory arrest time. Long-term observation (mean follow-up = 5.5 years) showed no left recurrent laryngeal nerve palsy or postoperative problems with left subclavian artery blood flow.ConclusionsFeneOS can minimize LSCA exposure because there is no need for LSCA reconstruction, reducing operation time and avoiding the risk of left recurrent laryngeal nerve injury and bleeding problems associated with LSCA exposure and anastomosis during left subclavian artery exposure.

Intraoperative Fenestration of Frozen Elephant Trunk (FET) and Total Arch Replacement for Aortic Dissection in Aberrant Subclavian Artery.

Total arch replacement (TAR) and the frozen elephant trunk (FET) routinely are performed to treat aortic dissection. When aortic dissection combines with the aberrant right subclavian artery (aRSA), routine TAR+FET will occlude the ostium of aRSA. But there is no consensus regarding the optimal surgical strategy to revascularize the aRSA. We seek an uncomplicated and less time-intensive way to reconstruct the aRSA. From July 2020 to April 2022, six patients with aortic dissection and aRSA underwent TAR+FET and intraoperative fenestration on the descending trunk. The mean age of the patients was 51.7 (SD 16.2; range 30.0-72.0). TAR+FET was performed via a median sternotomy and under cardiopulmonary bypass (CPB) and moderate hypothermic circulatory arrest (HCA). A fenestra of descending trunk was made intraoperative. There was no operative death in hospital and follow up. The average aortic cross-clamp time, SACP time, and lower body circulatory arrest time was 138.8 (SD 22.5; range 103.0-156.0) min and 28.3 (SD 3.9; range 25.0-35.0) min. Bleeding, neurological deficit, visceral ischemia, injury to the spinal cord, or organ dysfunction was not observed. Follow-up CTA showed the blood flow of aRSA was patent in all patients. TAR+FET and intraoperative fenestration on the descending trunk is an efficacious approach. It also reduces the difficulty of reconstruction the aRSA in aortic dissection patients.

Total arch replacement in octogenarians.

OBJECTIVESWe investigated the effect of a preoperative age ≥80 years on postoperative outcomes in patients who underwent isolated elective total arch replacement using mild hypothermic lower body circulatory arrest with bilateral antegrade selective cerebral perfusion.METHODSA total of 140 patients who had undergone isolated elective total arch replacement between January 2007 and December 2020 were enrolled in the present study. We compared postoperative outcomes between 30 octogenarian patients (≥80 years old; Octogenarian group) and 110 non-octogenarian patients (≤79 years old; Non-Octogenarian group).RESULTSOverall 30-day mortality and hospital mortality were 0% in both groups, and there was no significant difference in overall survival between the 2 groups (log-rank test, P = 0.108). Univariable Cox proportional hazard analysis showed that age as continuous variable was only the predictor of mid-term all-cause death (hazard ratio 1.08, 95% confidence interval 1.01–1.16; P = 0.037), but not in the Octogenarians subgroup (P = 0.119).CONCLUSIONSPreoperative age ≥80 years is not associated with worse outcomes postoperatively after isolated elective total arch replacement with mild hypothermic lower body circulatory arrest and bilateral antegrade selective cerebral perfusion.

Spinal cord injury during selective cerebral perfusion and segmental artery occlusion: an experimental study.

Since selective cerebral perfusion (SCP) has been used in aortic arch surgical procedures, the core temperature during lower body circulatory arrest (LBCA) has been steadily rising. Simultaneously, the use of a frozen elephant trunk (FET) graft has been increasing. The safe period of LBCA in relation to spinal cord ischaemic tolerance in combination with segmental artery occlusion by the FET procedure has not been defined. Sixteen pigs were assigned to undergo 65 (n = 10) or 90 min (n = 6) of SCP at 28°C with LBCA in combination with occlusion of the 8 uppermost segmental arteries in the thoracic (Th) aorta (15-20 cm FET, Th8-level). The follow-up period consisted of a 6-h intensive period and a 5-day observation period. Near-infrared spectroscopy of the collateral network was used to determine spinal cord oxygenation. The neurological status of the patients was evaluated daily, and the brain and the spinal cord were harvested for a histopathological analysis. Five out of 6 pigs after 90 min and 1 out of 10 pigs after 65 min of LBCA died within 48 h of multiorgan failure. Of the survivors in the 65-min group, 6 out of 9 had paraparesis/paraplegia; the remaining 3 reached normal function. The lone survivor after 90 min of LBCA was paraplegic. Nadir near-infrared spectroscopy of the collateral network values at Th8 and Th10 were 34 (±5) and 39 (±4), and they were reached within 35 min of SCP in both groups. An extended FET graft with LBCA and SCP durations >65 min at 28°C results in a poor outcome.

Reoperative Total Arch Repair Using a Trifurcated Graft and Selective Antegrade Cerebral Perfusion

BackgroundThis study reviews the outcomes of our reoperative total arch repair technique using a trifurcated graft and selective antegrade cerebral perfusion. MethodsFifty patients underwent reoperative total arch repair from January 2005 to September 2020, with either a one-stage repair (n = 9) or two-stage repair (n = 41). The two-stage technique includes minimal dissection of the mediastinal structures, an arch-first technique using a trifurcated graft, and construction of a classical elephant trunk through a partial transverse incision distally in the old graft or in the aorta just distal to the old graft. ResultsThe median age was 63 years. Chronic dissection was the most frequent indication (88%), and 98% had undergone a previous proximal aortic repair at a median interval of 3 years. The median cardiopulmonary bypass, myocardial ischemic, selective antegrade cerebral perfusion, and lower body circulatory arrest times were 226, 103, 97, and 98 minutes, respectively. The minimum nasopharyngeal and bladder temperature were 16.5°C and 20.0°C, respectively. Operative mortality was 2%, the incidence of stroke was 2%, and the incidence of spinal cord injury was 0%. Stage II repair was performed in 37 patients (open, 33 patients; endovascular, 4 patients), with 2 mortalities and no spinal cord injury. The median duration between stage I and II was 63 days. Survival and aortic event free rates at 3 years were 88.4% ± 4.9%, and 89.8% ± 5%, respectively. ConclusionsWe report a reoperative total arch repair technique that minimizes dissection of the cardiac structures, simplifies the distal anastomosis, and protects vital organs, such as the brain, heart, and spinal cord.

Total arch replacement in patients with chronic kidney disease.

We investigated the effect of preoperative renal dysfunction on postoperative outcomes in patients undergoing elective isolated total arch replacement (TAR) with mild hypothermic lower body circulatory arrest with antegrade selective cerebral perfusion (SCP). One hundred and forty-four patients who had undergone elective isolated TAR between January 2002 and December 2019 were retrospectively analyzed. Patients were divided into two groups according to whether their preoperative estimated glomerular filtration rate (eGFR) was lower than or higher than 60 ml/min/1.73 m2 . We compared perioperative data and mid-term outcomes after adjusting for patients' baseline characteristics using weighted logistic regression analysis and inverse probability of treatment weighting. More patients underwent postoperative stroke in the chronic kidney disease group compared with the normal group (2.8% vs. 0%, respectively; p = .049). Overall 30-day mortality and hospital mortality were 0% in both groups, and there was no significant difference in overall survival between the two groups (log-rank test, p = .129). Multivariate Cox proportional hazard analysis showed that eGFR < 60 ml/min/1.73 m2 was not an independent predictor (hazard ratio: 1.636, 95% confidence interval 0.829-3.231; p = .156). Preoperative eGFR <60 ml/min/1.73 m2 was not associated with worse outcomes after elective isolated TAR with mild hypothermic lower body circulatory arrest with antegrade SCP.

Effect of Selective Antegrade Cerebral Perfusion with Moderately Hypothermic Lower Body Circulatory Arrest on Biomarkers Related to Endothelial Function

Aim: This study aims to compare biomarkers related to endothelial function during selective antegrade cerebral perfusion with moderate hypothermic lower body circulatory arrest with that of standard cardiac surgery.Material and Methods: Thirty-six consecutive patients who underwent selective antegrade cerebral perfusion with moderately hypothermic lower body circulatory arrest at 28°C (study group) for aneurysms of the ascending aorta were prospectively compared with 36 patients who underwent standard cardiac surgery (control group) with conventional cardiopulmonary bypass. Nitric oxide, asymmetric dimethylarginine, hydrogen sulfide and total antioxidant capacity status and lactate levels in blood specimens obtained from the vena cava inferior were studied. Clinical results and biochemical parameters were evaluated.Results: Biomarkers related to endothelial function were found to be similar between the groups except for asymmetric dimethylarginine. The asymmetric dimethylarginine levels were lower, while lactate levels were significantly higher compared to the control group. When the patients with coronary artery disease were excluded from the analysis to rule out the predominance of coronary artery disease patients in one group as a confounding factor, the asymmetric dimethylarginine levels were found to be similar between the two subgroups.Conclusion: Low plasma levels of asymmetric dimethylarginine in the study group may have a protective role in endothelial nitric oxide synthesis. When patients with coronary artery disease were excluded from both group, biomarkers related to endothelial function were similar in both groups. We consider that endothelial functions are not affected adversely during short periods of moderately hypothermic lower body circulatory arrest.

Spinal cord collateral flow during antegrade cerebral perfusion for aortic arch surgery

ObjectiveWe aimed to monitor regional oxygen saturation levels using near-infrared spectroscopy in patients undergoing total aortic arch replacement and to determine the range of collateral flow via antegrade cerebral perfusion to the spinal cord during lower body circulatory arrest. MethodsEighteen consecutive patients undergoing total aortic arch replacement in our hospital were prospectively enrolled. Optodes of near-infrared spectroscopy were attached to the skin at the right and left forehead, and above the paravertebral muscles at the level of the third (T3) and tenth (T10) thoracic vertebra. Within- and between-group differences were compared using mixed-effect model repeated-measures analysis. ResultsRegional oxygen saturation levels, which had been rapidly declining immediately after circulatory arrest at a tympanic temperature of <25°C and a core temperature of <30°C, showed a rapid increase at the forehead with the initiation of antegrade cerebral perfusion (total flow rate 0.81 ± 0.08 L/min, perfusion pressure 37 ± 6 mm Hg, temperature 25°C). Saturation levels remained only partially elevated at the upper thoracic level (T3) and continued to decline without showing signs of recovery at the lower thoracic level (T10). ConclusionsAntegrade cerebral perfusion partially perfused the upper thoracic cord via collateral circulation from vertebral arteries through an anterior spinal artery, but it did not reach the lower thoracic cord sufficiently to change the oxygenation level. Cooling is a more important means of protection for the lower spinal cord during lower body circulatory arrest than is antegrade cerebral perfusion.

Perioperative Outcomes of Using Different Temperature Management Strategies on Pediatric Patients Undergoing Aortic Arch Surgery: A Single-Center, 8-Year Study.

Background: With the widespread application of regional low-flow perfusion (RLFP), development of surgical techniques, and shortened circulatory arrest time, deep hypothermia is indispensable for organ protection. Clinicians have begun to increase the temperature to reduce hypothermia-related adverse outcomes. The aim of this study was to evaluate the safety and efficacy of elevated temperatures during aortic arch surgery with lower body circulatory arrest (LBCA) combined with RLFP.Methods: We retrospectively analyzed data from 207 consecutive pediatric patients who underwent aortic arch repair with LBCA & RLFP between January 2010 and July 2017 and evaluated different hypothermia management strategies. The overall cohort was divided into three groups: deep hypothermia (DH, 20.0–25.0°C), moderate hypothermia (MoH, 25.1–30.0°C) and mild hypothermia (MH, 30.1–34.0°C).Results: The percentage of AKI-1 occurrences was significantly increased in the MH group (51.52%) compared to those in the DH (25.40%) and MoH (37.84%) groups (P = 0.036); prolonged hospital stay occurrences were decreased with elevated temperature (DH 47.62%, MoH 28.83%, MH 18.18%, P = 0.006). Neurological complications, peritoneal dialysis, hepatic dysfunction, 30-day hospital mortality, delay extubation occurrences were no significant among the groups. Logistic analysis showed that the MH group was negatively associated with post-op AKI-1 compared with the DH group [OR = 0.329 (0.137–0.788), P = 0.013], no differences were found between the MoH and the MH group. Compared to other groups, the intubation time (P = 0.006) and postoperative hospital stay (P = 0.009) were significantly decreased in the MH group. Multivariate logistic analysis showed hypothermia levels were not significant with prolonged hospital stay.Conclusions: This retrospective analysis demonstrated that for pediatric patients undergoing surgeries with RLFP & LBCA, three different gradient temperature management strategies are available: deep, moderate, and mild hypothermia. Utilizing mild or moderate hypothermia is safe and feasible. Although the number of AKI-1 occurrences in the MH group was significantly increased compared to those in the other groups, further analysis showed no significance in the MoH and MH group, mild hypothermia management is as safe as others when used appropriately.

Total arch replacement using a 4-branched graft with antegrade cerebral perfusion

ObjectiveTotal arch replacement (TAR) is an established standard surgical procedure. We report >1000 cases of TAR using a 4-branched graft with antegrade cerebral perfusion (ACP) during a 15-year period. MethodsSince May 2001, 1005 patients who underwent total aortic replacement (mean age 69.8 ± 11.2 years; range, 9-92 years; 744 male) underwent TAR with a 4-branched graft. All surgeries were performed under hypothermia with ACP. There were 252 emergent operations for acute aortic dissection or aneurysm rupture. Concomitant operations included coronary arterial bypass grafting in 196 patients, aortic valve repair or replacement in 64, and aortic root replacements in 38. ResultsThe operation time was 482 ± 171 minutes, cardiopulmonary time was 254 ± 94 minutes, cardiac ischemia time was 145 ± 51 minutes, ACP time was 160 ± 47 minutes, and lower body circulatory arrest time was 62 ± 16 minutes. The hospital mortality rate was 5.2%. The permanent neurological dysfunction rate was 3.6% and temporary neurological dysfunction rate was 6.4%. There were no spinal cord complications. The 5-year survival rate was 80.7% and 10-year survival rate was 63.1%. Fifteen patients (1.5%) underwent reoperation for the arch grafts because of a pseudoaneurysm (11 patients), hemolysis (3 patients), and infection (1 patient). ConclusionsTAR using a 4-branched graft with ACP could be accomplished with acceptable short- and long-term results.

Editor's Choice – Current Options and Recommendations for the Treatment of Thoracic Aortic Pathologies Involving the Aortic Arch: An Expert Consensus Document of the European Association for Cardio-Thoracic Surgery (EACTS) & the European Society for Vascular Surgery (ESVS)

Editor's Choice – Current Options and Recommendations for the Treatment of Thoracic Aortic Pathologies Involving the Aortic Arch: An Expert Consensus Document of the European Association for Cardio-Thoracic Surgery (EACTS) & the European Society for Vascular Surgery (ESVS)

Visceral oxidative stress during antegrade cerebral perfusion and lower body circulatory arrest

Background: Antegrade cerebral perfusion (ACP) is the standard neuroprotection method in aortic surgery. Visceral ischemia during this modality brings out some controversies. We aimed to investigate the level of oxidative stress at the lower part of body during ACP.Methods: Thirty consecutive patients underwent elective ascending aorta and hemiarch repair with ACP (without distal perfusion) were enrolled to study. The patients were enrolled into two groups which were based on 50th percentile of ACP duration (15 patients in each group). Blood samples from inferior vena cava at the end of ACP were collected to assess oxidative stress with biochemical parameters such as lactate, advanced oxidative protein products (AOPP) and thiol levels. Clinical follow-up parameters regarding to visceral and spinal cord ischemia were recorded. There were no clinical complications at both groups.Results: Mean ACP duration for the study group was found to be 15 min (10–28 min). Lactate, AOPP, and thiol levels were found to be similar between two groups. Furthermore, correlation analysis revealed only low level of correlation between ACP duration and lactate levels. Renal and liver function tests were found to be similar between groups.Conclusions: Immediate parameters (such as lactate, AOPP, and thiol) that show alterations in response to oxidative stress were not affected by the duration of ACP. Therefore, ACP without distal perfusion may not be harmful when conducted for short duration.