Selective Antegrade Cerebral Perfusion Time Research Articles

Total aortic arch replacement using the thoraflex hybrid prosthesis: early- and medium-term results from a Scandinavian center

Objective. The purpose of this study was to assess our early experience with the Thoraflex hybrid prosthesis. Design. This was a retrospective, single-center cohort study. Results. Between December 2014 and December 2019, 34 patients underwent total aortic arch replacement with the Thoraflex hybrid prosthesis. Fifteen of the patients had pre-operative chronic aortic dissection. The mean cardiopulmonary bypass time was 200 ± 35 min, aortic cross clamp time 114 ± 34 min, deep circulatory arrest time to the lower body 60 ± 22 min, and selective antegrade cerebral perfusion time 67 ± 24 min. The rate of stroke was 11.7% (4/34), paraparesis was 8.8% (3/34) and renal failure was 11.7% (4/34). No patient required permanent dialysis. Three (8.8%) patients died within the first 30 days postoperatively. All early deaths were due to stroke or spinal cord complications. During follow-up, an additional four patients died. Average follow-up was 32.4 ± 19.4 months (1102 patient-months) and was 100% complete. Survival at 12 months and 36 months was 88% ± 7.2% and 75% ± 12.7%, respectively. Conclusions. The Thoraflex hybrid prosthesis can be used in the setting of total aortic arch replacement with good early- and medium-term results. Stroke and spinal cord complications remain an important source of early mortality.

Combined femoral and axillary perfusion strategy for Stanford type a aortic dissection repair

BackgroundThe optimal cannulation strategy in surgery for Stanford type A aortic dissection is critical to patient survival but remains controversial. Different cannulation strategies have their own advantages and drawbacks during cardiopulmonary bypass. Our centre used a combined femoral and axillary perfusion strategy for the surgical treatment of type A aortic dissection. The purpose of this study was to review and clarify the clinical outcome of femoral artery cannulation combined with axillary artery cannulation for the treatment of Stanford type A aortic dissection.MethodsWe performed a retrospective study that included 327 patients who were surgically treated for type A aortic dissection in our institution from January 2017 to June 2019. Femoral and axillary artery cannulation was used to establish cardiopulmonary bypass in patients with type A aortic dissection. The demographic data, surgical data, and clinical results of the patients were calculated.ResultsFemoral artery combined with axillary artery cannulation was technically successful in 327 patients. The cardiopulmonary bypass time was 141.60 ± 34.89 min, and the selective antegrade cerebral perfusion time was 14.94 ± 2.76 min. The early mortality rate was 3.06%. The incidence of permanent neurologic dysfunction was 0.92%. Sixteen patients had postoperative renal insufficiency, and five patients had liver failure.ConclusionFemoral artery combined with axillary artery cannulation for type A aortic dissection can significantly improve the prognosis of patients, especially in terms of cerebral protection, and can reduce the occurrence of adverse malperfusion syndrome and neurological complications.

New 3-zone hybrid graft: First-in-man experience in acute type I dissection

ObjectiveAcute type I aortic dissection (AAD) represents a surgical emergency with time-dependent evolving complications. Frozen elephant trunk (FET) enables false lumen exclusion downstream but is still debated in AAD due to its greater dimension of surgery. To combine the benefits of fast proximal repair with the FET benefits, a 3-zone hybrid graft was developed consisting of an ascending polyester portion, an arch noncovered stent, and a descending stent graft. Mid-term results of this new technique are presented. MethodsA total of 6 patients (age mean 69 years) with type I AAD in critical status (Penn classification B n = 5, BC n = 1) were operated between July 2016 and April 2018 using the 3-zone hybrid graft. The device was implanted on the basis of strict compassionate use. Operations were performed under distal hypothermic circulatory arrest and selective antegrade cerebral perfusion (SACP). ResultsOperative mortality was 17% (n = 1). Mean crossclamp and SACP time were 92 and 34 minutes, respectively, but came down in the last 2 cases to 75/65 crossclamp and 23/24 SACP minutes each. During follow up, mean 19 ± 12 months, one endovascular extension downstream was performed. Imaging control demonstrated no anastomotic-related proximal entry and no true lumen collapse downstream. ConclusionsThe goal to achieve fast and reliable repair of complicated type I AAD down to midthoracic level seems to be achievable. Noncovered stenting of the head vessel's origin does not cause stenosis or obstruction. A multicenter studying of this concept is next.

Supra-aortic vessel reconstruction in total arch replacement for acute type A dissection: Comparison of en bloc and separate graft techniques

To compare the outcomes of the en bloc and branched graft techniques for supra-aortic vessel reconstruction in total arch replacement (TAR) for acute type A aortic dissection (ATAAD). In 53 ATAAD patients with intact supra-aortic arch vessels undergoing TAR, the arch vessels were reconstructed using the branched graft technique in 35 patients and en bloc technique in 18, i.e. reimplantation of the innominate artery and the left carotid artery (LCA) and transposition of left subclavian artery to LCA. The early and mid-term outcomes were compared between two groups. The selective antegrade cerebral perfusion time in en bloc group was significantly longer (33±10 vs 24±7min, p=0.001). Operative mortality was 5.7% (3/53), including 1 and 2 in the en bloc and branched graft groups, respectively (5.6% vs 5.7%, p=0.981). Stroke occurred in 1 patient. No spinal cord injury occurred. At mean 4.3±1.6 years, clinical and CT follow-up were complete in 100% and 86% (43/50). No cerebrovascular accidents or upper extremity claudication occurred. There were 4 deaths and 1 reintervention in follow-up. Survival was 88.6% and 88.9% at 3 months, and 83.3% and 88.6% at 6 months, 3 and 5 years in the en bloc and branched graft groups, respectively (p=0.597). The arch vessels were patent in 100% (43/43) without stenosis or aneurysm. The modified en bloc technique could achieve comparable early and mid-term outcomes to the branched graft technique in patients undergoing TAR for ATAAD. This approach may be an alternative technique for ATAAD patients with intact supra-aortic arch vessels.

Moderate Hypothermic Circulatory Arrest (≥ 28°C) with Selective Antegrade Cerebral Perfusion for Total Arch Replacement with Frozen Elephant Trunk Technique.

The optimal hypothermic level during circulatory arrest in aortic arch surgery remains controversial, particularly in frozen elephant trunk (FET) procedures. We describe herein our experience for total arch replacement with FET technique under moderate systemic hypothermic circulatory arrest (≥ 28°C) during selective antegrade cerebral perfusion. Between January 2009 and January 2016, 38 consecutive patients underwent elective total arch replacement for various aortic arch pathologies with FET technique using the E-vita Open hybrid prosthesis (Jotec GmbH, Hechingen, Germany). Selective unilateral or bilateral cerebral perfusion under moderate systemic hypothermic circulatory arrest (28.7°C ± 0.5°C) was used in all patients. Minimally invasive total arch replacement with FET via partial upper sternotomy was performed in 15 patients (39%) and in the remaining 23 patients (61%) via full sternotomy. Mean late follow-up was 3 ± 2 years and was 98% complete. Clinical data were prospectively entered into our institutional database. Cardiopulmonary bypass time accounted for 198 ± 58 minutes and the myocardial ischemic time 109 ± 29 minutes. Selective antegrade cerebral perfusion time was 55 ± 6 minutes. Lower body circulatory arrest time was 39 ± 11 minutes. Unilateral cerebral perfusion was performed in 31 patients (82%), and bilateral in 7 patients (18%). Intensive care unit stay was 4 ± 3 days. Thirty-day mortality was 5% (n = 2). Late survival at 3 years was 87 ± 3%. Two patients (5%) required reexploration for bleeding. Patients were discharged after a hospital length of stay of 7 ± 2 days. Postoperative permanent neurologic complication occurred in two patients (5%). Three patients (8%) experienced a transient neurologic disorder. New transient renal replacement therapy was necessary in three patients (8%). No spinal cord injury was noted. Our data suggest that moderate systemic hypothermic circulatory arrest (≥ 28°C) in combination with antegrade cerebral perfusion can safely be applied for total aortic arch replacement with FET and offers sufficient neurologic and visceral organ protection.

Single-centre experience with the frozen elephant trunk technique in 251 patients over 15 years†

Our goal was to present our 15-year experience (2001-2015) with the frozen elephant trunk (FET) technique. A total of 251 patients (82 with aortic aneurysms, 96 with acute aortic dissection type A, 4 with acute type B dissections, 52 with chronic aortic dissection type A, 17 with chronic type B dissection and 67 redo cases) underwent FET implantation with either the custom-made Chavan-Haverich (n = 66), the Jotec E-vita (n = 31) or the Vascutek Thoraflex hybrid (n = 154) prosthesis. The cases were assigned to an early period (2001-2011) and a contemporary period (2012-present). Mean cardiopulmonary bypass time, aortic cross-clamp time, circulatory arrest time and selective antegrade cerebral perfusion time were 241 ± 72, 125 ± 59, 56 ± 30 and 81 ± 34 min, respectively. Incidence of rethoracotomy for bleeding, stroke, spinal cord injury, prolonged ventilatory support (>96 h) and long-term dialysis were 18, 14, 2, 24 and 2%, respectively. The in-hospital mortality rate was 11% (in acute aortic dissection type A, 12%). Of the 2 patients with graft infections, 1 died and the other had a protracted hospital stay. There were 49 second-stage procedures in the downstream aorta: either open surgical [n = 25 (thoraco-abdominal, n = 15; descending, n = 6; infrarenal, n = 4)] or transfemoral endovascular (n = 23). Elective thoracic endovascular aneurysm repair R implantation was successful in all 23 cases. FET results are comparable with those of the published results of the conventional elephant trunk technique. FET is an ideal landing zone for subsequent transfemoral endovascular completion. Patients with graft infections may have dismal results.

Direct cannulation of arch vessels for total arch replacement

Objectives: To observe the efficiency and safety of direct and indirect three arch vessels’ cannulation for bilateral antegrade cerebral perfusion during total arch replacement. Methods: Between 2002 and 2014, 130 patients underwent total arch replacement with direct and 66 patients with indirect cannulation for antegrade cerebral perfusion under moderate hypothermia. Patients were assigned to the direct cannulation group based on the condition of the aortic arch vessels. Demographics and concomitant surgeries were similar in the two groups. Patient characteristics, surgical and haemodynamic measurements, and postoperative neurologic findings were observed. Results: Aortic cross-clamping (120 ± 42 vs 139 ± 65 min; p = 0.032) and cardiopulmonary bypass (178 ± 57 vs 206 ± 71 min; p = 0.025) times were lower in the direct cannulation group. There were no differences in overall hospital mortality (4% vs 6%; p = 0.87), selective antegrade cerebral perfusion time (91 ± 52 vs 100 ± 65 min; p = 0.185), and incidence of neurologic deficit (3% vs 9%; p = 0.07). Indirect cannulation led to more frequent re-exploration for bleeding (5% vs 13%; p = 0.0356). There was no difference in midterm survival (log-rank p = 0.103; mean follow-up times: 4.74 years (direct cannulation), 5.50 years (indirect cannulation)). Conclusion: Direct cannulation during mild systemic hypothermia yields excellent outcomes while reducing time and rate of reoperation for bleeding and can be used in total arch replacement without increasing morbidity and mortality.

Total aortic arch repair: risk factor analysis and follow-up in 199 patients.

Aortic arch surgery is associated with substantial perioperative risks. New prostheses as well as novel perfusion techniques have been developed to reduce the risks of these procedures. The routine application of these new techniques warrants reassessment of risk factors of aortic arch repair. Between April 2010 and December 2015, 199 patients [61% male, median age 63 years (interquartile range 52-70 years)] underwent total aortic arch repair in our institution. Forty-four per cent of the patients presented with acute aortic dissections (ADs, 32% with malperfusion), 22% with chronic aortic dissections (CDs), 34% with degenerative aneurysms, 24% underwent reoperations. Our surgical technique involved cold blood cardioplegia for cardiac procedures, non-cardioplegic continuous myocardial blood perfusion during aortic arch repair and early lower body reperfusion after distal aortic arch reconstruction. Anastomosis of head vessels is performed at the end of the procedure. Forty-four per cent of patients underwent aortic root surgery, 90% received a classical elephant trunk (ET) or frozen elephant trunk (FET). Median (interquartile range) cardiopulmonary bypass time, cardiac ischaemia time, hypothermic circulatory arrest time and selective antegrade cerebral perfusion time were 248 min (204-302), 105 min (51-150), 47 min (35-61) and 93 min (72-115), respectively. Operative mortality was 16%, stroke occurred in 10%, dialysis in 21% and spinal cord injury in 5%. Independent risk factors for mortality were age, rethoracotomy for bleeding, postoperative dialysis, maximum lactate value and maximum creatinine kinase-MB (CK-MB) value. 'Beating heart' aortic arch surgery significantly reduced the risk of mortality. Malperfusion syndrome and coronary artery bypass grafting were preoperative predictors of stroke. CD, preoperative renal dysfunction, operation time, rethoracotomy for bleeding and low cardiac output syndrome were risk factors for postoperative dialysis. Freedom from aortic reoperation was 91% (AD), 66% (CD) and 70% (aneurysm) after 2 years. Aortic arch repair remains a high-risk procedure, especially in multisegment aortic disease. Several peri- and postoperative factors predicted adverse outcome, indicating the need to further improve perioperative management (e.g. organ protection). Indications for FET treatment have to be thoroughly investigated (e.g. FET in CDs).

Total arch repair with open triple-branched stent graft placement for acute type A aortic dissection: Experience with 122 patients

To summarize the clinical experiences and midterm follow-up results of total arch repair with open triple-branched stent graft placement for acute type A aortic dissection. From June 2008 to March 2013, 122 patients (95 men and 27 women; mean age, 50.9 ± 10.4 years) with acute type A aortic dissection underwent total arch repair with open placement of a triple-branched stent graft under hypothermic cardiopulmonary bypass and selective cerebral perfusion. During the follow-up period, enhanced computed tomography and echocardiography were performed at 3 months postoperatively and annually thereafter. Placement of the triple-branched stent graft into the true lumen of the descending aorta, arch, and 3 arch vessels was technically successful in 121 patients. The cardiopulmonary bypass time was 186.50 ± 38.23 minutes, and the selective antegrade cerebral perfusion time was 31.97 ± 10.08 minutes. The in-hospital mortality was 4.93%. No permanent neurologic dysfunction or paraplegia was observed. Three patients were lost to follow-up. The mean follow-up period was 30.24 ± 12.35 months. After hospital discharge, 3 patients died. On the 3-month postoperative scans, complete thrombus formation around the triple-branched stent graft was observed in 89.38% of the patients. Endoleaks were detected in 12 patients; 8 patients refused any management for the endoleaks, but they maintained a good quality of life. The other 4 patients were successfully treated by additional surgery. Total arch repair with open triple-branched stent graft placement is an effective technique with satisfactory early and midterm results. This technique could be an attractive alternative to conventional total arch replacement.

Use of carotid–subclavian arterial bypass and thoracic endovascular aortic repair to minimize cerebral ischemia in total aortic arch reconstruction

Total aortic arch replacement typically requires hypothermic circulatory arrest, carrying risks of cerebral ischemia. We recently introduced left carotid-subclavian bypass before total aortic arch replacement with thoracic stent grafting to achieve hybrid arch reconstruction with short periods of selective antegrade cerebral perfusion. From 2004 to 2009, 332 patients underwent ascending aorta or arch replacements. Of these, 37 underwent total aortic arch replacement. In 2008, we began performing left carotid-subclavian bypass before subtotal arch replacement, with side-graft anastomoses to innominate and left carotid arteries. Patients then underwent aortic graft stent deployment to complete arch reconstruction. Twenty-eight patients underwent conventional arch replacement (group I); 9 underwent hybrid arch replacement (group II). Selective antegrade cerebral perfusion time in group I was 33.3 +/- 13.7 minutes versus 18.9 +/- 9.2 minutes in group II (P = .007). Among group I patients, 82% required hypothermic circulatory arrest (vs 0% in group II, P < .001). Mean cardiopulmonary bypass and aortic crossclamp times were longer in group I than group II (P < .05). Incidence of neurologic complications was 14% in group I (4/28) versus 0% (0/9) in group II, although this finding did not reach statistical significance (P = .55). Left carotid-subclavian bypass before arch replacement with staged thoracic stent grafting to achieve hybrid arch reconstruction was associated with decreased selective antegrade cerebral perfusion, cardiopulmonary bypass, and aortic crossclamp times and eliminated hypothermic circulatory arrest. This technique may minimize neurologic complications associated with arch replacement and provide a viable hybrid approach to patients with arch aneurysms and dissections.