Selective Cerebral Perfusion Research Articles

Femoral artery cannulation as a safe alternative for aortic dissection arch repair in the era of axillary artery cannulation.

BackgroundTo evaluate the safety and efficacy of femoral artery cannulation as an alternative to axillary artery cannulation, we retrospectively compared outcomes between patients with axillary or femoral artery cannulation during open aortic arch repair for type A aortic dissection (TAAD).MethodsBetween January 2014 and January 2019, 646 patients underwent open aortic arch repair with circulatory arrest for TAAD using antegrade selective cerebral perfusion (SACP) and were divided into two groups according to the site of arterial cannulation: an axillary artery group (axillary group, n=558) or a femoral artery group (femoral group, n=88). The axillary artery was considered as the primary cannulation site, and the femoral artery was used as an alternative when axillary artery cannulation was deemed unsuitable or had failed. Propensity score matching was performed to correct baseline differences.ResultsAfter propensity score matching, the patients’ characteristics were comparable between groups (n=85 in each). The incidence of in-hospital mortality (10.6% vs. 14.1%; P=0.642) and stroke (3.5% vs. 5.9%; P=0.720) were comparable between the axillary and femoral groups. The incidence of newly required dialysis was lower in the femoral group, but the difference was not statistically significant (34.1% vs. 20.0%; P=0.050). Other outcomes and major adverse events were comparable.ConclusionsFemoral artery cannulation produced similar perioperative outcomes to axillary cannulation after open arch repair for TAAD. The femoral artery can be used as a safe and effective alternative to the axillary artery for arterial cannulation in TAAD patients undergoing open arch repair.

Aortic arch surgery at 32°C: mild hypothermia and unilateral antegrade cerebral perfusion.

With development of antegrade cerebral perfusion, the necessity of deep hypothermic circulatory arrest (CA) in aortic arch surgery has been called into question. To minimize the adverse effects of hypothermia, surgeons now perform these procedures closer to normothermia. This study examined postoperative outcomes of hemiarch replacement patients using unilateral selective antegrade cerebral perfusion and mild hypothermic CA. Single-centre retrospective review of 66 patients undergoing hemiarch replacement with mild hypothermic CA (32°C) and unilateral selective antegrade cerebral perfusion between 2011 and 2018. Antegrade cerebral perfusion was delivered using right axillary artery cannulation. Postoperative data included death, neurological dysfunction, acute kidney injury and renal failure requiring new dialysis. Additional intraoperative metabolic data and blood transfusions were obtained. Eighty-six percent of patients underwent elective surgery. Mean age was 67 ± 3 years. Lowest mean core body temperature was 32 ± 2°C. Average CA was 17 ± 5 min. No intraoperative or 30-day mortality occurred. Survival was 97% at 1 year, 91% at 3 years and 88% at 5 years. Permanent and temporary neurological dysfunction occurred in 1 (2%) and 2 (3%) patients, respectively. Only 3 (5%) patients suffered postoperative stage 3 acute kidney injury requiring new dialysis. Intraoperative transfusions occurred in 44% of patients and no major metabolic derangements were observed. In patients undergoing hemiarch surgery, mild hypothermia (32°C) with unilateral selective antegrade cerebral perfusion via right axillary cannulation is associated with low mortality and morbidity, offering adequate neurological and renal protection. These findings require validation in larger, prospective clinical trials.

Risk Factors of Venoarterial Extracorporeal Membrane Oxygenation-Related Intracranial Hemorrhage in Children with Congenital Heart Disease.

To analyze the risk factors for intracranial hemorrhage (ICH) in congenital heart disease (CHD) patients supported with venoarterial extracorporeal membrane oxygenation (VA-ECMO). We performed a retrospective analysis of VA ECMO patients after open heart surgery in Shanghai Children's Medical Center from February 2017 to December 2018, with a total of 50 patients: 14 patients in the ICH group and 36 patients in the control group. Clinical data were analyzed and compared between groups to search for risk factors for ICH. The overall incidence of ICH was 28% (14/50). The in-hospital mortality rate of the ICH group was 57.1% (8/14) vs. 58.3% (21/36) in the control group. The proportion of neonates in the ICH group was 64.3% (9/14) vs. 25% in the control group (9/36) (p = 0.009), and the ICH incidence in extracorporeal cardiopulmonary resuscitation (ECPR) patients was 64.3% (9/14) vs. 13.9% (5/36) (p = 0.000). The percentage of selective cerebral perfusion in the ICH group was 64.3% (9/14) vs. 16.7% (6/36) (p = 0.001) in the control group, and the maximum procalcitonin (PCT) was 43.70 ± 30.48 ng/ml in the ICH group versus 26.92 ± 23.28 ng/ml (p = 0.050) in the control group. Multivariate analysis showed that neonates (odds ratio [OR] = 6.47 [1.09-38.46]), ECPR use (OR = 7.48 [1.26-44.41]), and maximum PCT values (OR = 1.04 [1.001-1.070]) were independent risk factors for ICH. The probability of ICH remains high in children supported with VA-ECMO after cardiac surgery. Neonatal patients, ECPR use, and PCT peak values are independent risk factors for ICH.

H-repair in supravalvular aortic stenosis.

H-repair in supravalvular aortic stenosis.

Mild hypothermia with selective antegrade cerebral perfusion during cardiopulmonary bypass and short-term outcomes in children with congenital heart defects

Background: Among the known risk factors for children undergoing surgery for congenital heart defect (CHD), temperature and blood flow during cardiopulmonary bypass (CPB), are two risk factors, which may be altered to improve outcomes. Moderate - to - deep hypothermia (MDH), traditionally used, has been associated with short/long-term neurologic sequelae, so there is a move towards mild hypothermia (MH) with selective antegrade cerebral perfusion (SACP). Aims and Objectives: To assess feasibility of mild hypothermia with selective antegrade cerebral perfusion during cardiopulmonary bypass as a cardiopulmonary bypass strategy in neonates and infants undergoing surgery for congenital heart defect. Materials and Methods: We conducted a retrospective chart review of neonates and infants who underwent SACP on CPB during CHD surgery at our tertiary care children's hospital between January 2014 and February 2017. We categorized all the patients into 2 groups - MH + SACP or MDH + SACP. We gathered data on preoperative, intra-operative and post-operative parameters. We analyzed comparative data using student t-test and chi-squared test with a significant p-value < 0.05. Results: There were 6 in the MH + SACP group and 7 in the MDH + SACP group, who underwent SACP on CPB during study period at our children's hospital. All the neonates and infants in the MH + SACP group survived at the hospital discharge with favorable neurologic outcomes. There was no statistically significant difference between the two groups for end organ dysfunction, ventilator days, hospital days, ICU and hospital mortality and PCPC/POPC at hospital discharge. Conclusions: Mild hypothermia with selective antegrade cerebral perfusion during cardiopulmonary bypass is a feasible cardiopulmonary bypass strategy in neonates and infants undergoing surgery for congenital heart defect.

Low-body-perfusion via an arterial sheath reduces inflammation after aortic arch reconstruction surgery

Pediatric cardiac surgeries involving aortic arch reconstruction are complex and require long cardiopulmonary bypass (CPB) times with deep hypothermic circulatory arrest (DHCA). Selective perfusion techniques have been developed to prevent the deleterious consequences of DHCA associated hypoperfusion. The effectivity of low body perfusion through cannulation of the femoral artery with an arterial sheath remains to be elucidated. We compared perfusion and inflammation in patients receiving selective antegrade cerebral perfusion (ACP) only to low body perfusion (LBP) in addition to ACP during DHCA for aortic arch reconstruction surgery. There was no difference in patient characteristics, cardiac pathologies, or performed procedures between ACP and LBP groups. Lactate levels increased after cardiac arrest in both groups. However, lactate levels were lower after 1 h reperfusion, at the end of extracorporeal circulation (ECC), and after surgery in LBP group compared to ACP only. Furthermore, creatinine was increased in ACP group on postoperative day 1 compared to LBP group but no acute kidney injury was observed in any group. IL-6 concentration increased in ACP group, while remained unchanged in LBP group compared to pre surgical values and were significantly lower compared to ACP group on postoperative days 1 and 2. LBP via an arterial sheath during cardiac arrest for aortic arch reconstruction surgery in addition to ACP, improves post ECC tissue perfusion as indicated by lower lactate levels and reduces creatinine levels suggesting milder kidney injury. LBP seems to prevent postoperative inflammation through a reduction in procedural duration or enhanced perfusion and thereby improves the outcome after aortic arch reconstruction surgery.

Aortic Arch Reconstruction in Infants Using Autologus Pericardium


 Background. Aortic arch hypoplasia is a congenital anomaly of the development of the aortic arch characterized by hemodynamically significant narrowing of one or more segments of the aortic arch. This defect occurs either as an isolated condition or combined with other congenital heart defects. The materials used to enlarge aorta for successful repair and prevention of postoperative complications range from the patient’s own aortic tissue (in most cases) to other materials (autopericardium, xenopericardium, pulmonary artery tissues, synthetic patches). An autologous pericardial patch is the most common, available and cheap option.
 The purpose of this work is toanalyze immediate and long-term results of our experience using autologous pericardium to reconstruct the aortic arch.
 Materials and methods. From 2011 to 2019 at the National M.M. Amosov Institute of Cardiovascular Surgery of the NAMS of Ukraine and Ukrainian Children’s Cardiac Center 16 infants underwent aortic arch repair using autologous pericardial patch. The group included 6 (37.5%) male and 10 (62.5%) female patients. The mean age of the patients was 1.3 ± 0.9 months (from 0.06 to 4.5 months), the average body weight was 3.8 ± 1.6 kg (from 2.2 to 8.7 kg). The average body surface area was 0.24 ± 0.05 m?. Antegrade selective cerebral perfusion was performed in all the patients during the aortic arch reconstruction.
 Results. Hospital mortality was 6.2% (n = 1). The cause of death was not related to the reconstruction technique. The average duration of cardiopulmonary bypass was 142.5 ± 38.5 minutes, the aortic cross-clamp time was 76.9 ± 33.7 minutes, and the time of selective cerebral perfusion was 50.4 ± 25.4 minutes. Six patients (37.5%) in the early postoperative period had delayed sternal closure. According to echocardiographic data at discharge, the average pressure gradient at the site of aortic arch reconstruction was 15 ± 5.5 mm Hg, the left ventricular ejection fraction was 65.9 ± 5.9%.
 The mean follow-up period ranged from one month to 6.1 years (mean 2.8 ± 2.3 years). There were no deaths in the long-term period. Four (25%) patients developed aortic arch restenosis in the postoperative period. One patient presented with an aortic arch aneurysm 1 month after the initial operation. There were no cases of compression of the trachea, main bronchi, neurological complications in the follow-up period.
 Conclusions. The use of autologous pericardium in aortic arch reconstruction is an effective and safe procedure for infants with good immediate and long-term results. The study showed that autologous pericardium may be an acceptable alternative to reconstruct the aortic arch. A large percentage of reinterventions encourages more thorough removal of ductal tissues and determining the size of the autopericardial patch.

Does supply meet demand? A comparison of perfusion strategies on cerebral metabolism in a neonatal swine model

ObjectiveWe aimed to determine the effects of selective antegrade cerebral perfusion compared with other perfusion strategies on indices of cerebral blood flow, oxygenation, cellular stress, and mitochondrial function. MethodsOne-week-old piglets (n = 41) were assigned to 5 treatment groups. Thirty-eight were placed on cardiopulmonary bypass. Of these, 30 were cooled to 18°C and underwent deep hypothermic circulatory arrest (n = 10), underwent selective antegrade cerebral perfusion at 10 mL/kg/min (n = 10), or remained on continuous cardiopulmonary bypass (deep hypothermic cardiopulmonary bypass, n = 10) for 40 minutes. Other subjects remained on normothermic cardiopulmonary bypass (n = 8) or underwent sham surgery (n = 3). Novel, noninvasive optical measurements recorded cerebral blood flow, cerebral tissue oxyhemoglobin concentration, oxygen extraction fraction, total hemoglobin concentration, and cerebral metabolic rate of oxygen. Invasive measurements of cerebral microdialysis and cerebral blood flow were recorded. Cerebral mitochondrial respiration and reactive oxygen species generation were assessed after the piglets were killed. ResultsDuring hypothermia, deep hypothermic circulatory arrest piglets experienced increases in oxygen extraction fraction (P < .001), indicating inadequate matching of oxygen supply and demand. Deep hypothermic cardiopulmonary bypass had higher cerebral blood flow (P = .046), oxyhemoglobin concentration (P = .019), and total hemoglobin concentration (P = .070) than selective antegrade cerebral perfusion, indicating greater oxygen delivery. Deep hypothermic circulatory arrest demonstrated worse mitochondrial function (P < .05), increased reactive oxygen species generation (P < .01), and increased markers of cellular stress (P < .01). Reactive oxygen species generation was increased in deep hypothermic cardiopulmonary bypass compared with selective antegrade cerebral perfusion (P < .05), but without significant microdialysis evidence of cerebral cellular stress. ConclusionsSelective antegrade cerebral perfusion meets cerebral metabolic demand and mitigates cerebral mitochondrial reactive oxygen species generation. Excess oxygen delivery during deep hypothermia may have deleterious effects on cerebral mitochondria that may contribute to adverse neurologic outcomes. We describe noninvasive measurements that may help guide perfusion strategies.

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.

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.

Application of moderate hypothermia while performance of the aortal arch reconstruction in new-born babies in conditions of selective antegrade cerebral perfusion

Objective. To estimate a security of application of moderate hypothermia while performing the aortal arch reconstruction in new-born babies in conditions of selective antegrade cerebral perfusion.&#x0D; Materials and methods. In 2010-2019 yrs period in Amosov National Institute of Cardiovascular Surgery and Scientific-Practical Medical Centre of Pediatric Cardiology and Cardio-Surgery in 64 new-born babies the aortal arch reconstruction was performed in conditions of selective antegrade cerebral perfusion in moderate hypothermia. In the investigation only patients with a two-ventricle physiology, in whom further two-ventricular correction was conducted, were included. There were 48 (75%) boys and 16 (25%) girls. Median age of the patients was (1.6 ± 0.8) mo, median body mass - (3.8 ± 1.1) kg, median square of the body surface - (0.24 ± 0.04) m². Echocardiographic investigation and neurosonography were the main diagnostic procedures.&#x0D; Results. Hospital mortality have constituted 4.7% (3 patients died). The death cases were not connected with the brain protection procedure. Duration of artificial blood circulation period have had constituted (138.4 ± 58.8) min at average, aortal clamping - (83.1 ± 40 min), selective antegrade cerebral perfusion - (24.4 ± 8.8) min. In 10 (15,6%) patients in early postoperative period the sternum persisted open. In 4 (6.2%) patients in early postoperative period convulsions were noted, which were treated successfully medicinally. Median stay in the Department of Reanimation and Intensive Therapy have constituted (7.1 ± 4.1) days. In late follow-up period the patients were seen from 1 mo till 8.5 yrs. No one patient died. While elective neurosonography conduction the brain pathological changes were absent. The neurological complications symptoms were absent as well.&#x0D; Conclusion. Selective antegrade cerebral perfusion with moderate hypothermia constitutes effective and secure method of the brain protection while performance of the aortal arch reconstruction in new-born babies, using median surgical approach in conditions of artificial blood circulation.

Neurological changes and outcomes of paediatric surgery of the aortic arch using selective cerebral perfusion

IntroductionThe aims of this article are to analyse the neuropsychological changes in the medium–term in children subjected to aortic arch surgery using selective cerebral perfusion (SCP), as well as to detect any modifiable factors in the surgical technique that may contribute to minimising the subsequent neurological involvement. Material and methodsInclusion criteria were established as: aortic arch disease operated on using SCP during the first year of life, between 10 August 2004 and 24 May 2016, biventricular physiology, and gestational age greater than 31 weeks. In the absence of a chromosomal disease, they were classified, from a neurological point of view, using the Rankin score. Children over 4-years of age were subjected to intelligence studies, including attention level, development, and psycho-lingual skills. ResultsThe study included a total of 82 patients with a mean age of 1.8 months. The mean SCP flow was 32ml/kg/min. The mean time of SCP was 31min. The overall mortality of the series was 14.8%. Neurological dysfunction was observed in 35.9% of patients, and the following were detected as risk factors: surgery in patients less than 10-days-old, duration of SCP greater than 40min, and the time required for the cooling down and/or warming-up. Attention deficit was diagnosed in 35.2% of patients greater than 5-years-old. ConclusionsPatients operated on using SCP in in the first year of life required a neuropsychological follow-up, and there are modifiable surgical factors that may have an influence on neurological development.

Acute peripheral ischemia in healthy female patient: an indirect and unanticipated diagnosis of spontaneous thrombus in the aortic arch

BackgroundIn this case we discuss the management of a pediculated floating thrombus in the aortic arch which led to peripheral embolization and acute ischemia oft he left leg.Case presentationA healthy 46 year old female patient presented with pain in her left leg and progressive numbness. Computed Tomography Angiography (CTA) showed an acute ischemia of the left leg (Rutherford 2 B) with a 2 cm thrombus distal of the aortic bifurcation. Emergency operation with embolectomy, selective thrombembolectomy and patch plasty on the tibioperoneal trunk and local lysis was performed. As part of a further diagnostic examination a thoracic CT scan has been performed revealing a pediculated-floating 2 cm thrombus in the aortic arch. Four days after the initial operation thrombus excision via a minimally invasive access way has been performed. After initiation of the extracorporeal circulation, selective unilateral antegrade cerebral perfusion has been established in mild (30–32 °C) systemic hypothermia. Patients postoperative course was uneventful. Histological evaluation of the mass demonstrated thrombotic material without evidence of infection or malignacy.ConclusionA pediculated spontaneous thrombus may develop in aortic arch in patients without traditional risk factors or family history of embolic events. Two stage operation was feasible and safe.

Single-stage repair for coarctation with ventricular septal defect: results of 100 cases at a single centre.

The outcomes of the single-stage surgical repair of aortic arch hypoplasia (AAH) and/or coarctation of the aorta (CoA) associated with ventricular septal defect (VSD) remain controversial, especially in a lower middle-income country. This study reports the results of a single-stage repair protocol at our institution for AAH/CoA with VSD using selective cerebral perfusion. This retrospective study included 100 consecutive patients who underwent single-stage repair via median sternotomy using selective cerebral perfusion for AAH/CoA with VSD from July 2010 to March 2017. The patients consisted of 65 males and 35 females. The median age of the patients was 67 days (range 4-2266 days); the median weight was 3.8 kg (range 2.1-15 kg). The average cardiopulmonary bypass time was 132 ± 28 min, the aortic cross-clamp time was 92 ± 23 min and the selective cerebral perfusion time was 33 ± 10 min. The survival rate of all patients was 94.7 ± 2.3%, with an in-hospital mortality of 5% and no late mortality at a median follow-up of 37 months (range 4-96 months). Four patients required reoperation due to recoarctation. The overall event-free survival rate following surgery was 87.1%. The median pressure gradient across the anastomosis at the last follow-up was 8.3 ± 2.8 mmHg. Multivariate logistic regression analysis revealed proximal aortic arch obstruction as a predictor of mortality (odds ratio = 3.8). The aortic isthmus diameter was identified as a predictor for reintervention by Cox regression (hazard ratio = 6.7). Single-stage repair for AAH/CoA with VSD is safe and feasible in a developing country.

Dramatic increase in serum trypsinogens, SPINK1 and hCGβ in aortic surgery patients after hypothermic circulatory arrest

The concentrations of several diagnostic markers have been found to increase dramatically in critically ill patients with a severe disturbance of normal physiological homeostasis, without indication of the diseases they are normally associated with. To prevent false diagnoses and inappropriate treatments of critically ill patients, it is important that the markers aiding the selection of second-line treatments are evaluated in such patients and not only in the healthy population and patients with diseases the markers are associated with. The levels of trypsinogen isoenzymes, the trypsin inhibitor serine peptidase inhibitor Kazal type 1 (SPINK1), hCG and hCGβ, which are used as pancreatitis and cancer markers, were analyzed by immunoassays from serum samples of 17 adult patients who have undergone surgery of the ascending aorta during hypothermic circulatory arrest (HCA) with optional selective cerebral perfusion. Highly elevated levels of trypsinogen-1, -2 and -3, SPINK1 and hCGβ were observed in patients after HCA. This was accompanied by increased concentrations of S100β and NSE. In conclusion, this study highlights the importance of critically evaluating the markers used for aiding selection of second line of treatments in critically ill patients.

Different hypothermic and cerebral perfusion strategies in extended arch replacement for acute type a aortic dissection: a retrospective comparative study

BackgroundThe optimal hypothermic level in total arch replacement with stented elephant trunk implantation for acute type A aortic dissection (aTAAD) has not been established, and the superiority of unilateral or bilateral cerebral perfusion remains a controversial issue. Therefore, we evaluated the application of moderate hypothermic circulatory arrest (MHCA) with a core temperature of 29 °C and bilateral selective antegrade cerebral perfusion in aTAAD treated by total arch replacement with stented elephant trunk implantation.MethodsFrom July 2019 to January 2020, 25 aTAAD patients underwent total arch replacement with stented elephant trunk implantation via MHCA (29 °C) and bilateral selective antegrade cerebral perfusion (modified group). Thirty-six patients treated by the same procedure with MHCA (25 °C) and unilateral selective antegrade cerebral perfusion during this period were selected as controls.ResultsThere were no differences between the two groups of patients in terms of age, sex, incidence of hypertension, malperfusion, and pericardial effusion, although the incidence of cardiac tamponade was higher in the modified group (control 2.8%, modified 20%; P = 0.038). The lowest mean circulatory arrest temperature was 24.6 ± 0.9 °C in the control group, and 29 ± 0.8 °C in the modified group (P < 0.001). In-hospital mortality was 4.9% (3/61) for the entire cohort (control 8.3%, modified 0; P = 0.262). The incidence of permanent neurologic deficit was 4.9% (control 8.3%, modified 0; P = 0.262). There were no significant differences in the occurrence of temporary neurological deficit, renal failure, and paraplegia between groups. The rate of major adverse events in the modified group was lower (30.6% vs. 4%, P = 0.019). A shorter duration of ventilation and ICU stay was identified in the modified group, as well as a reduced volume of drainage within the first 48 h and red blood cell transfusion.ConclusionsThe early results of MHCA (29 °C) and bilateral selective antegrade cerebral perfusion applied in total arch replacement with stented elephant trunk implantation for aTAAD were acceptable, providing similar inferior cerebral and visceral protection compared with that of the conventional strategy. A higher core temperature may account for the shorter duration of ventilation and ICU stay, as well as a reduced volume of drainage and red blood cell transfusion.

Single-Stage Treatment of Extensive Aortic Pathology Using the Frozen Elephant Trunk Procedure.

Extensive pathology involving the aortic arch and descending aorta traditionally has been treated with two open procedures. We report our institutional experience with a single stage frozen elephant trunk procedure for treatment of extensive aortic pathology. Between June 2018 and October 2019, nine patients (eight males, 89%, mean age 61 ± 6 years) with extensive aortic pathology were operated using the frozen elephant trunk procedure. Five (56%) patients underwent primary operation for chronic arch and proximal descending aneurysm in two (22%) patients, chronic type B aortic dissection in two (22%) patients and penetrating aortic ulcer in one (11%) patient. The other four (44%) patients received reoperative surgery for chronic post-dissection aneurysms. For organ protection during the aortic arch procedure, we used selective antegrade cerebral perfusion and mild systemic hypothermia at 28°C. Early mortality was not observed. A single (11%) patient developed focal stroke. Unilateral vocal cord palsy was present in two (22%) patients. Spinal cord injury was not observed. Reexploration for bleeding was required in two (22%) patients. Prolonged ventilation, liver and kidney failure as well as cardiac morbidity were not observed. Two patients (22%) with anticipated Endoleak type Ib received TEVAR extension at follow up. Mid-term mortality was observed in two (22%) patients, due to pneumonia. The frozen elephant trunk procedure can be used for a single-stage treatment of patients with extensive aortic pathology, due to chronic degenerative aneurysms or post-dissection aneurysms involving the aortic arch and the descending aorta, with acceptable mortality and morbidity.

Repair of residual aortic dissections with frozen elephant trunk technique

In this study, we present our mid-term results of reoperation with the frozen elephant trunk procedure due to patent false lumen-related complications in patients previously undergoing supracoronary aortic repair for acute type A aortic dissection. Between January 2013 and September 2018, a total of 23 patients (17 males, 6 females; mean age 51.5±9.7 years; range, 30 to 67 years) who underwent ascending aortic replacement due to type A aortic dissection and, later, frozen elephant trunk procedure for residual distal dissection were included. For diagnostic purposes and follow-up, computed tomography angiography was performed in all patients, and both re-entry and aortic diameters were evaluated. Echocardiography was used to evaluate cardiac function and valve pathologies. The Ishimaru zone 0 (n=11, 47.8%), Ishimaru zone 1 (n=1, 4.3%), Ishimaru zone 2 (n=4, 17.4%), and Ishimaru zone 3 (n=7, 30.4%) were used for frozen elephant trunk stent graft fixation. The mean duration of cardiopulmonary bypass and antegrade selective cerebral perfusion was 223.9±71.2 min and 88.9±60.3 min, respectively. In-hospital mortality was 13%, while there was one (4.3%) aortic-related death and four (17.4%) re-interventions during follow-up. Early repair should be considered in the presence of persistent dissections due to alarmingly high mortality rates of reoperations. Reoperation with the frozen elephant trunk procedure has acceptable results and the decision of the procedure to be performed should be based on preoperative risk factors of the patient.

A new cannula for antegrade selective cerebral perfusion.

ObjectiveOur aim was to perform antegrade selective cerebral perfusion with a different surgical technique using a new type of cannula.MethodsThis cannula has been designed to be introduced in the supra-aortic vessels directly using a standard guidewire technique (Seldinger technique). The cannula can also be inserted from the ostia of a vessel if preferred. Furthermore, this device can be introduced before the institution of hypothermic circulatory arrest and opening the aortic arch.ResultsWe have performed operations on 5 patients so far using this cannula. No stroke or spinal cord injuries were detected. At the moment, both intraoperatively and at computed tomography scan follow-up, no significant stenosis of the cannulation sites were noted. Follow-up at 2 years found that patients are alive and free from new major neurological events.ConclusionsTransarterial introduction using the Seldinger technique of our cannula (AV Flow; MedEurope Srl, Bologna, Italy) represents an alternative to the current well-established techniques. The major advantages we describe are complete cerebral protection throughout the hypothermic circulatory arrest and easier arch vessels reimplantation or hemiarch operations.

The surgical management of type IA endoleak after thoracic endovascular aortic repair

Our goal was to investigate the surgical strategy for type Ia endoleak after thoracic endovascular aortic repair (TEVAR) by reporting our experiences. From November 2012 to September 2019, a total of 23 patients received surgical management for type Ia endoleak after TEVAR. The operations included total arch replacement with the frozen elephant trunk technique in 15 patients, direct closure of the endoleak in 2 patients, hybrid aortic arch repair in 4 patients, arch debranching with TEVAR in 1 patient and left common carotid artery to left subclavian artery bypass with TEVAR in 1 patient. Among 21 patients with cardiopulmonary bypass (CPB), the mean CPB and aortic cross-clamp times were 146.7 ± 42.2 and 81.0 ± 43.3 min, respectively. The selective cerebral perfusion time was 18.8 ± 8.2 min in 17 patients with hypothermic circulatory arrest. The in-hospital mortality was 8.7% (2/23). Type Ia endoleak was sealed successfully after surgery in 95.5% (21/22) of patients. The follow-up data were available for all 21 survivors. The median follow-up period was 18 months (range 1-84 months). During the follow-up period, a total of 8 patients died or had aortic events, including 5 deaths and 6 aortic events. Different surgical strategies could be selected to treat patients with type Ia endoleak after TEVAR, with acceptable early and late outcomes.