Selective Antegrade Cerebral Perfusion Research Articles

SURGERY OF TYPE A AORTIC DISSECTIONS: WHAT HAS CHANGED? SINGLE CENTER EXPERIENCE

Abstract Introduction Our knowledge on type A aortic dissection (ATAAD) has evolved, and there are some differences in surgical approach. In this paper, we focused on what changed in the surgical treatment of ATAAD and on the impact of these changes on patients’ survival, analyzing our center experience and comparing it with literature latest evidences. Materials and Methods From 2010 to 2022, 342 consecutive patients underwent surgery for Acute Type A Aortic dissection at our institution. In order to identify changes in these patients’ management over time, we divided our population in two groups according to the year of surgery: Group A before 2016 (146 patients) and Group B after 2016 (196 patients). Results Patients from Group B (after 2016) showed more comorbidities and a worse clinical presentation than patients from Group A (chronic kidney disease 9.2% vs 2.1% p=0.006, neurological deficit on admission 8.7% vs 0% p < 0.001, cardiac tamponade 12.2% vs 0.7% p < 0.001, and pre–operative catecholamine support 4.1% vs 0% p=0.012). Also of pre–operative malperfusion was more frequent (coronary 6.6% vs 0% p < 0.001 and peripheral 6.6% vs 0% p < 0.001). In Group B in 70.4% of the population the circulatory arrest with antegrade selective cerebral perfusion was used vs 30.8% in Group A (p < 0.001) and we find a bigger percentage of emiarch replacement (43.4% vs 23.3% P=0.008) and total arch replacement (27% vs 13.7% p=0.017) than in Group A. In–hospital mortality resulted to be 10.2% with no differences between the groups. Neurological events (p<0.001) and post–operative dialysis (p=0.036) were more frequent in Group B. On the other hand, in Group A post–operative cardiac tamponade (9.65 vs 3.1% p=0.007) and red blood cells transfusions were higher. Conclusions Nowadays surgery is performed on more critical patients with higher surgical risk and the tendency is to perform more complex operations with replacement of a largest portion of the diseased aorta in order to reduce reintervention rate. Recently, clinical studies and guidelines highlighted the importance of creating a multidisciplinary aortic team to discuss and manage these patients in order to assure the best treatment options to each patient and to reduce mortality and morbidity.

Antegrade cerebral perfusion via the right subclavian artery during open distal arch or proximal descending aortic repair from left thoracotomy.

In the current endovascular era, open surgery through left posterolateral thoracotomy (PLT) with moderate to deep hypothermic circulatory arrest (DHCA) remains an alternative for treating chronic distal arch or proximal descending aortic diseases, allowing cardiovascular surgeons to definitively repair the aorta in a single stage. When utilizing this approach, this report illustrates an alternative surgical technique for antegrade body perfusion during cooling, antegrade selective cerebral perfusion (ASCP), and rewarming, through a prosthetic graft on the right subclavian artery (RSA). This report shows the safety and feasibility of this technique during open distal arch and/or proximal descending aortic surgery through left PLT, after shifting the patient from a supine to the right lateral decubitus position.

Results of using thoraflextm hybrid prothesis for the treatment of complex aortic disease at Viet Duc University Hospital

Background: The aim of this study was to introduce and evaluate the early results after the frozen elephant trunk (FET) procedure with ThoraflexTM Hybrid prothesis for the treatment of complex aortic disease at Viet Duc University Hospital. Methods: This is a retrospective descriptive study of all acceptable patients after the frozen elephant trunk (FET) procedure with ThoraflexTM Hybrid prothesis at Viet Duc University Hospital from January 2021 to May 2023. Results: There were 21 patients with a male rate of 85.7% and an average age 58.2±10 years old (range 40–73). History of patients with hypertension: 19 (90.5%); post-dissection aortic aneurysm: 2 (9.5%) patients. By cause, the number of patients with thoracic aortic aneurysm was 03 (14.3%), acute aortic dissection type A was 16 (76.1%), and aortic dissection type B was 02 (9.5%). In which there were 16 cases of emergency surgery (76.1%). Replacement of the aortic arch was performed under moderate hypothermic (280 °C on average) circulatory arrest and bilateral selective antegrade cerebral perfusion with permanent monitoring of cerebral tissue oxygenation by the MASIMO machine. Average cardio-pulmonary bypass time, aortic cross clamp time, distal hypothermic circulatory arrest time, and operating time were 137,5±22,9 minutes; 86,3±17,6 minutes; 25,2±8,9 minutes; and 7,7±10,3 hours. The average ventilation time, length of intensive care unit stay, and hospital stay were 7,2±9,7 days, 18,8±20,7 days, and 19,9 ± 6,5 days. There was one patient with post-operative cerebrospinal fluid drainage. No patient had bleeding complications, recurrent nerve palsy, reoperation, or in-hospital mortality. Conclusion: The initial results after the frozen elephant trunk procedure with ThoraflexTM Hybrid prothesis for the treatment of complex aortic disease at Viet Duc University Hospital were safe, good, and feasible.

Experience with aortic arch inclusion technique using artificial blood vessel for type A aortic dissection: an application study

BackgroundThis study aimed to elucidate the methodology and assess the efficacy of the aortic arch inclusion technique using an artificial blood vessel in managing acute type A aortic dissection (ATAAD).MethodsWe conducted a retrospective review of 18 patients (11 males and 7 females, average age: 56.2 ± 8.6 years) diagnosed with ATAAD who underwent total aortic arch replacement (TAAR) using an artificial vascular “inclusion” between June 2020 and October 2022. During the operation, deep hypothermic circulatory arrest (DHCA) and selective antegrade cerebral perfusion (ACP) of the right axillary artery were employed for brain protection. The ‘inclusion’ total aortic arch replacement and stented elephant trunk (SET) surgery were performed.ResultsFour patients underwent the Bentall procedure during the study, with one additional patient requiring coronary artery bypass grafting (CABG) due to significant involvement of the right coronary orifice. Three patients died during postoperative hospitalization. Other notable complications included two cases of postoperative renal failure necessitating continuous renal replacement therapy (CRRT), one case of postoperative double lower limb paraplegia, and one case of cerebral infarction resulting in unilateral impairment of the left upper limb. Eleven patients underwent computed tomography angiography (CTA) examinations of the aorta three months to one-year post-operation. The CTA results revealed thrombosis in the false lumen surrounding the aortic arch stent in seven patients and complete thrombosis of the false lumen around the descending aortic stent in eight patients. One patient had partial thrombosis of the false lumen around the descending aortic stent, and another patient’s false lumen in the thoracic and abdominal aorta completely resolved after one year of follow-up.ConclusionsIncorporating vascular graft in aortic arch replacement simplifies the procedure and yields promising short-term outcomes. It achieves the aim of total arch replacement using a four-branch prosthetic graft. However, extensive sampling and thorough, prolonged follow-up observations are essential to fully evaluate the long-term results.

Redo extended thoracic aortic replacement from aortic root to descending aorta via anterolateral thoracotomy with partial sternotomy for graft infection

A 59-year-old male underwent Bio-Bentall + total arch replacement with a frozen elephant trunk for acute type A aortic dissection before at another hospital. He was diagnosed as mediastinitis and previous graft infection, followed by wound closure with omental flap installation. However, the recurrent graft infection from the aortic root to the FET in the descending aorta was diagnosed by 18-fluorodeoxyglucose positron emission tomography. Redo modified Bio-Bentall procedure, total arch replacement, and descending aortic replacement for previous graft infection using anterolateral thoracotomy with partial sternotomy was successfully performed. Anterolateral thoracotomy with partial sternotomy provided not only the excellent exposure from the aortic root to the descending aorta but also sure myocardial protection with antegrade and selective delivery of cold crystalloid cardioplegia and stable brain protection with antegrade selective cerebral perfusion. The patient is doing well without recurrent of infection after 2 years of the operation.

Optimal antegrade cerebral perfusion flow in patients undergoing surgery for acute type A aortic dissection: A retrospective single-center analysis.

Systemic hypothermia with bilateral antegrade selective cerebral perfusion (ASCP) is the preferred cerebral protective strategy for type A aortic dissection surgery. The optimal ASCP flow rate remains uncertain and the target flow cannot always be reached due to pressure limitations. The aim of this study was to assess the correlation between ASCP flow and regional cerebral oxygen saturation (rSO2). A retrospective analysis was performed on 140 patients with acute type A aortic dissection who underwent surgery with moderate hypothermic circulatory arrest and bilateral ASCP between 2015 and 2021. Pearson correlation analysis was performed between ASCP flow and rSO2. The median circulatory arrest duration was 46.5 (IQR:37.0-61.0) minutes. There was no significant correlation between ASCP flow and rSO2 for both the right (r = -.02, p = .851), and the left hemisphere (r = - .04, p = .618). The rSO2 values for ten patients who received > 10mL/kg/min flow did not differ significantly from 130 patients who received 10mL/kg/min or less for both the left hemisphere (p = .135), and the right hemisphere (p = .318). The ASCP flow was 5.1 (IQR:5.0- 6.5) mL/kg/min in five patients with, and 7.2 (IQR:5.8-8.3) mL/kg/min in 135 patients without a watershed infarction (p = .098). There was no correlation between ASCP flow rate and rSO2 in patients with acute type A aortic dissection. Furthermore, ASCP flow below 10mL/kg/min was not associated with a reduction in rSO2. Definitive associations between ASCP flow and neurological outcome after type A aortic dissection surgery need further investigation.

Aortic arch repair with extended end-to-side anastomosis in neonates and infants with transverse arch hypoplasia

Background/Aim: The use of patches to repair the aortic arch is believed to have a positive effect on long-term morbidity. In this study, perioperative and follow-up data of patients who underwent transverse arch repair with a patch were compared with the data of patients who underwent end-to-end anastomosis (ESA). Methods: In this retrospective cohort study, the data of 27 patients (including 18 newborns) who underwent aortic arch repair at the Gazi Yasargil Education and Research Hospital between January 2018 and April 2023 were analyzed. The inclusion criteria included a diagnosis of proximal and distal transverse aortic arch hypoplasia, an age younger than 12 months of age, and the completion of aortic arch repair using cardiopulmonary bypass. Patients who underwent recoarctation repair due to residual obstruction, patients with single ventricular physiology, and patients who underwent aortic arch repair via a lateral thoracotomy without undergoing cardiopulmonary bypass were excluded from the study. The patients were divided into two groups. Group 1 included individuals who underwent aortic anterior wall expansion with autologous pericardium in addition to ESA; Group 2 included patients who underwent ESA only. Results: The median age of the patients was 21 days (range: 6–365 days), and the median body weight of the cohort was 3.5 kilograms (range: 2.4–8.9 kilograms). Enlargement with autologous pericardial patch was applied to 11 patients (40.7%). Surgical procedures performed in addition to arch repair included eight ventricular septal defect closures, six instances of pulmonary banding, three atrial septal defect closures, and one subvalvular pulmonary stenosis repair. The in-hospital mortality rate was 11.1% (n=3). Those three patients died due to sepsis. The median follow-up period was 152 days (range: 10–1316 days). Recoarctation requiring re-intervention did not occur in any of the studied patients. The antegrade selective cerebral perfusion time was statistically significantly longer in patients who underwent aortic arch repair using a patch (P=0.03). Conclusion: Repair of the arch with a patch may contribute to a reduction in long-term mortality and morbidity. However, there is a need for more comprehensive and long-term follow-up studies to verify these findings.

The impact of circulatory arrest with selective antegrade cerebral perfusion on brain functional connectivity and postoperative cognitive function

Aortic surgery is one of the most challenging types of surgeries, which is possibly related to cognitive sequelae. We aimed to investigate the changes in resting-state functional connectivity (rsFC) associated with intraoperative circulatory arrest (CA) in aortic surgery, exploring the relationship between the altered connectivity and postoperative cognitive functions. Thirty-eight patients participated in this study (14 with CA, 24 without). Functional magnetic resonance imaging was scanned on the fifth day after surgery or after the resolution of delirium if it was developed. We assessed the differences in the development of postoperative cognitive changes and rsFC between patients with and without CA. The occurrence of postoperative delirium and postoperative cognitive dysfunction was not significantly different between the patients with and without the application of CA. However, patients with CA showed increased in posterior cingulate cortex-based connectivity with the right superior temporal gyrus, right precuneus, and right hippocampus, and medial prefrontal cortex-based connectivity with the dorsolateral prefrontal cortex. The application of moderate hypothermic CA with unilateral antegrade cerebral perfusion is unlikely to affect aspects of postoperative cognitive changes, whereas it may lead to increased rsFC of the default mode network at a subclinical level following acute brain insults.

Association between Bilateral Selective Antegrade Cerebral Perfusion and Postoperative Ischemic Stroke in Patients with Emergency Surgery for Acute Type A Aortic Dissection-Single Centre Experience.

Acute type A aortic dissection (ATAAD) is a surgical emergency with a mortality of 1-2% per hour. Since its discovery over 200 years ago, surgical techniques for repairing a dissected aorta have evolved, and with the introduction of hypothermic circulatory arrest and cerebral perfusion, complex techniques for replacing the entire aortic arch were possible. However, postoperative neurological complications contribute significantly to mortality in this group of patients. The aim of this study was to determine the association between different bilateral selective antegrade cerebral perfusion (ACP) times and the incidence of postoperative ischemic stroke in patients with emergency surgery for ATAAD. Patients with documented hemorrhagic or ischemic stroke, clinical signs of stroke or neurological dysfunction prior to surgery, that died on the operating table or within 48 h after surgery, from whom the postoperative neurological status could not be assessed, and with incomplete medical records were excluded from this study. The diagnosis of postoperative stroke was made using head computed tomography imaging (CT) when clinical suspicion was raised by a neurologist in the immediate postoperative period. For selective bilateral antegrade cerebral perfusion, we used two balloon-tipped cannulas inserted under direct vision into the innominate artery and the left common carotid artery. Each cannula is connected to a separate pump with an independent pressure line. Near-infrared spectroscopy was used in all cases for cerebral oxygenation monitoring. The circulatory arrest was initiated after reaching a target core temperature of 25-28 °C. In total, 129 patients were included in this study. The incidence of postoperative ischemic stroke documented on a head CT was 24.8% (31 patients), and postoperative death was 20.9% (27 patients). The most common surgical technique performed was supravalvular ascending aorta and Hemiarch replacement with a Dacron graft in 69.8% (90 patients). The mean cardiopulmonary bypass time was 210 +/- 56.874 min, the mean aortic cross-clamp time was 114.775 +/- 34.602 min, and the mean cerebral perfusion time was 37.837 +/- 18.243 min. Using logistic regression, selective ACP of more than 40 min was independently associated with postoperative ischemic stroke (OR = 3.589; 95%CI = 1.418-9.085; p = 0.007). Considering the high incidence of postoperative stroke in our study population, we concluded that bilateral selective ACP should be used with caution, especially in patients with severely calcified ascending aorta and/or aortic arch and supra-aortic vessels. All efforts should be made to minimize the duration of circulatory arrest when using bilateral selective ACP with a target of less than 30 min, in hypothermia, at a body temperature of 25-28 °C.

Validation of a new model of selective antegrade cerebral perfusion with circulatory arrest in rats.

Selective antegrade cerebral perfusion (SACP) is adopted as an alternative to deep hypothermic circulatory arrest (DHCA) during aortic arch surgery. However, there is still no preclinical evidence to support the use of SACP associated with moderate hypothermia (28-30°C) instead of DHCA (18-20°C). The present study aims to develop a reliable and reproducible preclinical model of cardiopulmonary bypass (CPB) with SACP applicable for assessing the best temperature management. A central cannulation through the right jugular vein and the left carotid artery was performed, and CPB was instituted.Animals were randomized into two groups: normothermic circulatory arrest without or with cerebral perfusion (NCA vs SACP). EEG monitoring was maintained during CPB. After 10min of circulatory arrest, rats underwent 60min of reperfusion. After that, animals were sacrificed, and brains were collected for histology and molecular biology analysis. Power spectral analysis of the EEG signal showed decreased activity in both cortical regions and lateral thalamus in all rats during the circulatory arrest. Only SACP determined complete recovery of brain activity and higher power spectral signal compared to NCA (p < 0.05). Histological damage scores and western blot analysis of inflammatory and apoptotic proteins like caspase-3 and Poly-ADP ribose polymerase (PARP) were significantly lower in SACP compared to NCA. Vascular endothelial growth factor (VEGF) and RNA binding protein 3 (RBM3) involved in cell-protection mechanisms were higher in SACP, showing better neuroprotection (p < 0.05). SACP by cannulation of the left carotid artery guarantees good perfusion of the whole brain in this rat model of CPB with circulatory arrest. The present model of SACP is reliable, repeatable, and not expensive, and it could be used in the future to achieve preclinical evidence for the best temperature management and to define the best cerebral protection strategy during circulatory arrest.

Frozen elephant trunk technique for aortic arch surgery: the Bordeaux University Hospital experience with Thoraflex hybrid prosthesis.

Aortic arch surgery still represents a challenge, and the frozen elephant trunk (FET) allows a one-step surgery for complex aortic diseases. The aim of the study was to analyze the results of patients undergoing FET procedure for aortic arch surgery at Bordeaux University Hospital. Patients undergoing FET procedure for multisegmented aortic arch pathologies were analyzed in this single-center retrospective study. Further subgroup analyses were performed according to the degree of urgency of the operation (elective versus emergent surgery) and cerebral protection technique: bilateral selective antegrade cerebral perfusion (B-SACP) versus the unilateral one (U-SACP), regardless of the degree of urgency. From August 2018 to August 2022, 77 consecutive patients (64.1±9.9 years, 54 males) were enrolled: 43 (55.8%) for elective surgery and 34 (44.2%) in emergency. Technical success was 100%. 30-day mortality was 15.6% (N.=12, 7% elective vs. 26.5% emergent, P=0.043). Six (7.8%) non-disabling strokes occurred (1.9% B-SACP vs. 20% U-SACP, P=0.021). Median follow-up was 1.11 years (interquartile range, 0.62-2.07). The 1-year overall survival was 81.6±4.45%. The elective group showed a survival trend when compared to the emergency one (P=0.054). However, further examination at landmark analysis elective surgery showed a better survival trend compared to emergency surgery up to 1.78 years (P=0.034), after which significance was lost (P=0.521). Thoraflex hybrid prosthesis for FET technique demonstrated feasibility and satisfactory short-term clinical outcomes, even in emergent settings. In our practice B-SACP seems to offer better protection and less neurological complications compared to U-SACP, nevertheless further analyses are warranted.

Perioperative cerebral perfusion in aortic arch surgery: a potential link with neurological outcome.

The aim of this study was to examine whether perioperative changes in cerebral blood flow (CBF) relate to postoperative neurological deficits in patients undergoing aortic arch surgery involving antegrade selective cerebral perfusion (ASCP). We retrospectively analysed data from patients who underwent aortic arch surgery involving ASCP and perioperative transcranial Doppler assessments. Linear mixed-model analyses were performed to examine perioperative changes in mean bilateral blood velocity in the middle cerebral arteries, reflecting changes in CBF, and their relation with neurological deficits, i.e. ischaemic stroke and/or delirium. Logistic regression analyses were performed to explore possible risk factors for postoperative neurological deficits. In our study population (N = 102), intraoperative blood velocities were lower compared to preoperative levels, and lowest during ASCP. Thirty-six (35%) patients with postoperative neurological deficits (ischaemic stroke, n = 9; delirium, n = 25; both, n = 2) had lower blood velocity during ASCP compared to patients without (25.4 vs 37.0 cm/s; P = 0.002). Logistic regression analyses revealed lower blood velocity during ASCP as an independent risk factor for postoperative neurological deficits (odds ratio = 0.959; 95% confidence interval: 0.923, 0.997; P = 0.037). Lower intraoperative CBF during ASCP seems independently related to postoperative neurological deficits in patients undergoing aortic arch surgery. Because CBF is a modifiable factor during ASCP, our observation has significant potential to improve clinical management and prevent neurological deficits.

Selective antegrade cerebral perfusion: how to perfuse?

Journal Article Accepted manuscript Selective antegrade cerebral perfusion: How to perfuse? Get access Tim Berger, MD, Tim Berger, MD Department of Cardiovascular Surgery, University Hospital Freiburg, Heart Centre Freiburg, Freiburg, Germany, University of Freiburg, Faculty of Medicine, Freiburg, Germany Address for correspondence: Tim Berger, MD, University Hospital—Heart Centre Freiburg, Südring 15, 79189 Bad Krozingen Germany, Phone: +49 7633 402 6251, Fax: +49 761 270 25500, E-mail: tim.berger@uniklinik-freiburg.de Search for other works by this author on: Oxford Academic PubMed Google Scholar Bartosz Rylski, MD, Bartosz Rylski, MD Department of Cardiovascular Surgery, University Hospital Freiburg, Heart Centre Freiburg, Freiburg, Germany, University of Freiburg, Faculty of Medicine, Freiburg, Germany Search for other works by this author on: Oxford Academic PubMed Google Scholar Martin Czerny, MD, MBA, Martin Czerny, MD, MBA Department of Cardiovascular Surgery, University Hospital Freiburg, Heart Centre Freiburg, Freiburg, Germany, University of Freiburg, Faculty of Medicine, Freiburg, Germany Search for other works by this author on: Oxford Academic PubMed Google Scholar Maximilian Kreibich, MD, MHBA Maximilian Kreibich, MD, MHBA Department of Cardiovascular Surgery, University Hospital Freiburg, Heart Centre Freiburg, Freiburg, Germany, University of Freiburg, Faculty of Medicine, Freiburg, Germany Search for other works by this author on: Oxford Academic PubMed Google Scholar European Journal of Cardio-Thoracic Surgery, ezad139, https://doi.org/10.1093/ejcts/ezad139 Published: 12 April 2023 Article history Received: 29 March 2023 Accepted: 30 March 2023 Published: 12 April 2023

A case report: A severe juxta-ductal coarctation of aorta with post coarctation aortic aneurysm

Objective: Coarctation of aorta with post coarctation aneurysm is a congenital malformation of the aorta which usually occurs in undiagnosed and long standing coarctation and present in third to fifth decade of life. In this case, we present technique of differential hypothermia used to repair coarctation and post coarctation aneurysm: meticulous repair of coarctation segment and aneurysm without compromising blood flow to the vital organs distal to the coarctation segment. Case report: A 44-year old male patient with severe juxtaductal coarctation of aorta with post coarctation aortic aneurysm who was relatively asymptomatic until he presented with hypertension since 6 months in his fifth decade of life was admitted to our hospital. The patient was managed with surgery of coarctation of aorta and aneurysm repair using dual arterial cannulation and maintaining selective antegrade cerebral perfusion. Conclusion: Differential hypothermia allows meticulous repair of coarctation segment and post coarctation aneurysm without compromising blood flow to vital organs and and better neurological recovery. Key words: Aortic coarctation, aortic surgery, post coarctation aneurysm, ventral repair

Total arch replacement with extended branched stented anastomosis frozen elephant trunk repair for type A dissection improves operative outcome.

Emergency surgical repair is the standard treatment for acute aortic dissection type A. However, the surgical risk of total arch replacement remains high. The Viabahn Open Revascularization TEChnique has been used for supra-aortic reconstruction during total arch replacement. This Cleveland Clinic technique is called "branched stented anastomosis frozen elephant trunk repair." Our total arch replacement with reconstructed extended branched stented anastomosis frozen elephant trunk repair requires no unnecessary cervical artery exposure. We compared the outcomes of extended branched stented anastomosis frozen elephant trunk repair and conventional total arch replacement in acute aortic dissection type A. We compared the clinical course of patients undergoing total arch replacement using sutureless direct branch vessel stent grafting with frozen elephant trunk (extended branched stented anastomosis frozen elephant trunk repair) for acute aortic dissection type A with patients undergoing conventional total arch replacement. For the procedure, the aortic arch was transected circumferentially distal to the brachiocephalic artery origin. Frozen elephant trunk was fenestrated by heating with a cautery, and the self-expandable stent graft was delivered into the branch vessels through the fenestration. Of 58 cases, 21 and 37 were classified in the extended branched stented anastomosis frozen elephant trunk repair and conventional total arch replacement groups, respectively. The times (minutes) of selective antegrade cerebral perfusion (75±24, 118±47), total operation (313±83, 470±151), and cardiopulmonary bypass (195±46, 277±96) were significantly better in the extended branched stented anastomosis frozen elephant trunk repair group (P<.001). Six surgical deaths occurred: 2 (9%) in the extended branched stented anastomosis frozen elephant trunk repair group and 4 (10%) in the conventional total arch replacement group. In all cases, only 1 patient (2%) in the conventional total arch replacement group had a branch artery-related complication during the postoperative follow-up period. In the extended branched stented anastomosis frozen elephant trunk repair group, blood product use significantly decreased (P<.05). Extended branched stented anastomosis frozen elephant trunk repair has shown comparable safety and efficacy to conventional total arch replacement and can be used for acute aortic dissection type A emergency repair. It optimizes true lumen perfusion and facilitates supra-aortic artery remodeling.

Initial Asian experience of the branched E-vita open NEO in complex aortic pathologies.

Aortic arch pathology often requires staged segmental repairs. Total aortic arch replacement with frozen elephant trunk (FET) offers surgical options for these pathologies. The Jotec E-vita Open NEO™ branched prosthesis was introduced in 2020; we sought to share our initial experience focusing on the prosthesis selection strategies, surgical techniques, anastomosis-bleeding and graft-oozing control methods, and early clinical outcomes from two Asian centers. We performed a retrospective cohort study in patients with aortic arch pathologies who underwent total arch replacement using the FET procedure with Jotec E-vita Open NEO™ branched prosthesis from two Asian centers between October 2020 and August 2021. The primary outcome was overall 30-day mortality, and the secondary outcomes were operative complications. Twenty-five consecutive patients underwent total arch replacement with FET with the novel hybrid prosthesis. Overall 30-day mortality from both centers was 0%. Overall mean operative, cardiopulmonary bypass, hypothermic circulatory arrest, and selective antegrade cerebral perfusion times were 353.4±80.5, 183.2±39.6, 57.2±14.7, and 138.2±28.6 minutes, respectively. No patient developed stroke. Permanent spinal cord injury (SCI) was recorded in one patient (4%) and one (4%) had transient lower limb weakness that resolved after spinal drainage. There was no requirement of re-sternotomy for hemostasis. We reported a multicenter Asian case series with the novel FET hybrid prosthesis demonstrating the feasibility and safety of promising initial clinical outcomes. The technique of circumferential reinforcement of vascular anastomosis for hemostasis may be one of the methods for lowering the rates of re-sternotomy for hemostasis, and proper surgical or transfusion strategies would overcome the excessive oozing of the prosthesis. Long-term follow-up is required for further evaluation of aortic pathology progression and device-related outcomes.

Management of Wilms’ Tumor with Cavoatrial Extension Using Deep Hypothermic Cardiac Arrest and Selective Antegrade Cerebral Perfusion

ABSTRACT Wilms’ tumor is one of the most common genitourinary malignancies in children. It may be associated with extension of the tumor in the inferior vena cava (IVC) (4%–8%) and right atrium (1%–3%) of cases. In such a scenario, management of cases is further challenging and involves a multidisciplinary approach with medical and surgical specialties, including pediatric cardiac surgery involvement. We present a case of successful management of Wilms’ tumor involving the IVC, right atrium, and hepatic veins where we achieved synchronous surgical resection of both renal and vascular extension. Case management involved anticipated complications involving temperature management, fluid balance, and hemodynamic fluctuation due to intermittent IVC compression, bleeding, arrhythmias, complications involving deep hypothermic cardiac arrest and selective antegrade cerebral perfusion and possibility of tumor embolism.

Normothermic Versus Hypothermic Norwood Procedure.

Either deep hypothermia with circulatory arrest or hypothermic perfusion with antegrade selective cerebral perfusion is used during the Norwood procedure for hypoplastic left heart syndrome. Normothermic perfusion has been described for pediatric patients. The aim of this study was to compare the early outcomes of patients undergoing the Norwood procedure with antegrade selective cerebral perfusion under hypothermia with the procedure under normothermia. From 2005 to 2020, 117 consecutive patients with hypoplastic left heart syndrome underwent the Norwood procedure: 68 (58.2%) under hypothermia and 49 (41.8%) under normothermia. Antegrade selective cerebral perfusion flow was adjusted to maintain right radial arterial pressure above 50 mm Hg, and a flow rate of 40 to 50 mL kg-1 min-1. Baseline characteristics, operative data, and postoperative outcomes including lactate recovery time were compared. The baseline characteristics and cardiovascular diagnosis were similar in both groups. The normothermic group had a significantly shorter bypass time (in minutes) of 90.31 (±31.60) versus 123.63 (±25.33), a cross-clamp time of 45.24 (±16.35) versus 81.93 (±16.34), and an antegrade selective cerebral perfusion time of 25.61 (±13.84) versus 47.30 (±14.35) (P < .001). There were no statistically significant differences in the immediate postoperative course, or in terms of in-hospital mortality, which totaled 9 (18.4%) in the normothermic group, and 10 (14.9%) in the hypothermic group (P = .81). The normothermic Norwood procedure with selective cerebral perfusion is feasible and safe in terms of in-hospital mortality and short-term outcomes. It is comparable to the standard hypothermic Norwood with selective cerebral perfusion.

Clinical outcomes of mild versus moderate hypothermic circulatory arrest with antegrade cerebral perfusion in adult aortic arch surgery: A systematic review and meta-analysis.

In adult aortic arch surgery, moderate hypothermic circulatory arrest (HCA) with selective antegrade cerebral perfusion (SACP) (MoHACP) is widely used, but the application of mild HCA with SACP (MiHACP) is still controversial. This meta-analysis aimed to compare clinical outcomes using MiHACP or MoHACP. Studies comparing outcomes of MiHACP or MoHACP in adult aortic arch surgery were searched from four databases from inception through April 2022. Primary outcomes were postoperative permanent neurological deficit (PND), temporary neurological deficit (TND), and mortality. Secondary outcomes included other common complications. Meta-analysis was conducted using a random-effects model in all cases. Eleven comparative studies were included, with 1555 patients in MiHACP group and 1499 patients in MoHACP group, and the mean HCA temperature were 29.4°C and 24.8°C, respectively. Postoperative PND, TND, mortality, paraplegia, dialysis, tracheotomy, reexploration for bleeding, and chest tube drainage volume were comparable in the two groups (p > 0.05). Ventilator time, intensive care unit and in-hospital length of stay were shorter in MiHACP group (p < 0.05). Outcomes were also comparable or had some benefits in MiHACP group when subgroup analyses were conducted according to hemiarch or total arch replacement, unilateral or bilateral SACP, HCA time, emergency aortic dissection surgery, and concomitant procedure. The present meta-analysis showed acceptability of MiHACP in adult aortic arch surgery. Results need to be taken with caution as moderate risk of bias and very low quality of evidence were observed in this meta-analysis. Randomized controlled trials are needed for further analysis.

Validity of direct bilateral axillary arterial cannulation in emergency surgery for acute type A aortic dissection

To assess the validity and long-term outcomes of direct bilateral axillary arterial cannulation for acute type A aortic dissection. Between 2003 and 2020, 208 consecutive patients with acute type A aortic dissection underwent emergency surgical repair. Cardiopulmonary bypass was attempted to establish direct bilateral axillary arterial cannulation and bicaval drainage. Antegrade selective cerebral perfusion was established by axillary perfusion and direct cannulation of the left common carotid artery. Ascending aortic, partial arch, and extended total aortic arch replacement were performed in 50 (24.0%), 7 (3.4%), and 151 (72.6%) patients, respectively. Aortic root surgery and coronary artery bypass grafting were performed concomitantly in 23 and seven patients, respectively. Cardiopulmonary bypass was attempted only through bilateral axillary cannulation in all patients but was successful in 13 (6.3%) patients without bilateral axillary cannulation. No postoperative complications occurred related to this technique. There were seven hospital deaths (early mortality rate, 3.4%). Five patients had postoperative reoperation for bleeding, and nine (4.3%) were transferred to other hospitals due to postoperative permanent cerebral infarction, particularly two with arm ischemia. The 10-year survival rate of patients who underwent emergency surgical repair with this technique was 71.4%. Direct bilateral axillary arterial cannulation followed by selective cerebral perfusion was successful in 93.7% of patients and this may be an optimal solution for providing stable outcomes after emergency surgery for acute type A aortic dissection. However, we experienced two complications of arm ischemia, attention should be paid to potential arm ischemia.