Cerebral Protection Techniques Research Articles

Cerebral hypoperfusion resulting from improper cannulation positioning during aortic dissection surgery: a case report

BackgroundSelective antegrade cerebral perfusion (sACP) is a crucial cerebral protection technique employed during aortic dissection surgeries involving cardiopulmonary bypass. However, postoperative neurological complications, particularly those related to cannulation issues and perfusion problems, remain a significant concern.Case PresentationThis case report details an unusual instance where a 38-year-old male patient with Marfan syndrome experienced cerebral hypoperfusion during emergency surgery for Stanford Type A aortic dissection. Despite following standard protocols, a significant drop in regional cerebral oxygen saturation (rSO2) and abnormal blood pressure fluctuations were observed shortly after initiating sACP via the innominate artery. After initial attempts to optimize perfusion flow proved ineffective, the cannulation position was adjusted, leading to improvements. Nevertheless, the patient subsequently exhibited signs of cerebral hypoperfusion and was found to have suffered a new cerebral infarction.ConclusionsThis case report underscores the importance of precise cannula placement during sACP procedures and the dire consequences that can arise from improper positioning. It emphasizes the need for continuous monitoring and prompt intervention in cases of abnormal cerebral oxygenation and blood pressure, as well as the value of considering cannulation-related issues as potential causes of postoperative neurological complications.

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.

Cerebral Protection Strategies and Stroke in Surgery for Acute Type A Aortic Dissection.

Perioperative stroke remains a devastating complication in the operative treatment of acute type A aortic dissection. To reduce the risk of perioperative stroke, different perfusion techniques can be applied. A consensus on the preferred cerebral protection strategy does not exist. To provide an overview about the different cerebral protection strategies, literature research on Medline/PubMed was performed. All available original articles reporting on cerebral protection in surgery for acute type A aortic dissection and neurologic outcomes since 2010 were included. Antegrade and retrograde cerebral perfusion may provide similar neurological outcomes while outperforming deep hypothermic circulatory arrest. The choice of arterial cannulation site and chosen level of hypothermia are influencing factors for perioperative stroke. Deep hypothermic circulatory arrest is not recommended as the sole cerebral protection technique. Antegrade and retrograde cerebral perfusion are today's standard to provide cerebral protection during aortic surgery. Bilateral antegrade cerebral perfusion potentially leads to superior outcomes during prolonged circulatory arrest times between 30 and 50 min. Arterial cannulation sites with antegrade perfusion (axillary, central or carotid artery) in combination with moderate hypothermia seem to be advantageous. Every concept should be complemented by adequate intraoperative neuromonitoring.

Whole Body Retrograde Perfusion Combined With Central Aortic Perfusion Strategy in the Repair of Distal Arch Pathology Through a Lateral Thoracotomy

ObjectiveTo compare the results of the hypothermic circulatory arrest (HCA) + retrograde whole-body perfusion (RBP) technique with those of deep hypothermic circulatory arrest (DHCA-only) approach. MethodsLimited data are available on cerebral protection techniques when distal arch repairs are performed through a lateral thoracotomy. In 2012, the RBP technique was introduced as adjunct to HCA during open distal arch repair via thoracotomy. We reviewed the results of the HCA + RBP technique compared with those of the DHCA-only approach. From February 2000 to November 2019, 189 patients (median age, 59 [IQR, 46 to 71] years; 30.7% female) underwent open distal arch repair via lateral thoracotomy to treat aortic aneurysms. The DHCA technique was used in 117 patients (62%, median age 53 [IQR, 41 to 60] years), whereas HCA + RBP was used in 72 patients (38%, median age 65 [IQR, 51 to 74] years). In HCA + RBP patients, cardiopulmonary bypass was interrupted when systemic cooling achieved isoelectric electroencephalogram; once the distal arch had been opened, RBP was then initiated via the venous cannula (flow of 700 to 1000 mL/min, central venous pressure <15 to 20 mm Hg). ResultsThe stroke rate was significantly lower in the HCA + RBP group (3%, n=2) compared with the DHCA-only (12%, n=14) (P=.031), despite longer circulatory arrest times in HCA + RBP compared with the DHCA-only (31 [IQR, 25 to 40] minutes vs 22 [IQR, 17 to 30] minutes, respectively; P<.001). Operative mortality for patients undergoing HCA + RBP was 6.7% (n=4), whereas for those undergoing DHCA-only it was 10.4% (n=12) (P=.410). The 1-, 3-, and 5-year age-adjusted survival rates for the DHCA group are 86%, 81%, and 75%, respectively. The 1-, 3-, and 5-year age-adjusted survival rates for the HCA + RBP group are 88%, 88%, and 76%, respectively. ConclusionThe addition of RBP to HCA in the treatment of distal open arch repair via a lateral thoracotomy is safe and provides excellent neurological protection.

Does deep hypothermic circulatory arrest with versus without retrograde cerebral perfusion affect the outcomes after proximal aortic arch aneurysm and acute type A aortic dissection repair? Different pathologies and cerebral protection techniques with similar results.

Hypothermic circulatory arrest is used for proximal and total aortic arch correction in patients with aortic arch aneurysm and acute or chronic type A aortic dissection. Different cerebral perfusion techniques have been proposed for reducing morbidity and mortality rate. The study of Arnaoutakis et al. showed that deep hypothermic circulatory arrest with or without retrograde cerebral perfusion for proximal aortic aneurysm and acute type A aortic dissection correction had similar results with regard to morbidity and mortality rate. In addition, the short circulatory arrest time contributes for favorable outcomes of these patients. Although antegrade cerebral perfusion with hypothermic circulatory is widely used by many cardiac surgeons, deep hypothermic circulatory arrest with or without retrograde cerebral perfusion remains an alternative and safe method for brain protection in patients undergoing proximal aortic arch aneurysm or acute type A aortic dissection repair.

Cerebral protection in aortic arch surgery: systematic review and meta-analysis.

Consensus regarding optimal cerebral protection strategy in aortic arch surgery is lacking. We therefore performed a systematic review and meta-analysis to assess outcome differences between unilateral antegrade cerebral perfusion (ACP), bilateral ACP, retrograde cerebral perfusion (RCP) and deep hypothermic circulatory arrest (DHCA). A systematic literature search was performed in Embase, Medline, Web of Science, Cochrane and Google Scholar for all papers published till February 2021 reporting on early clinical outcome after aortic arch surgery utilizing either unilateral, bilateral ACP, RCP or DHCA. The primary outcome was operative mortality. Other key secondary endpoints were occurrence of postoperative disabling stroke, paraplegia, renal and respiratory failure. Pooled outcome risks were estimated using random-effects models. A total of 222 studies were included with a total of 43 720 patients. Pooled postoperative mortality in unilateral ACP group was 6.6% [95% confidence interval (CI) 5.3–8.1%], 9.1% (95% CI 7.9–10.4%), 7.8% (95% CI 5.6–10.7%), 9.2% (95% CI 6.7–12.7%) in bilateral ACP, RCP and DHCA groups, respectively. The incidence of postoperative disabling stroke was 4.8% (95% CI 3.8–6.1%) in the unilateral ACP group, 7.3% (95% CI 6.2–8.5%) in bilateral ACP, 6.4% (95% CI 4.4–9.1%) in RCP and 6.3% (95% CI 4.4–9.1%) in DHCA subgroups. The present meta-analysis summarizes the clinical outcomes of different cerebral protection techniques that have been used in clinical practice over the last decades. These outcomes may be used in advanced microsimulation model. These findings need to be placed in the context of the underlying aortic disease, the extent of the aortic disease and other comorbidities.Prospero registration number: CRD42021246372METC: MEC-2019-0825

Association between Duration of Deep Hypothermic Circulatory Arrest and Surgical Outcome in Patients with Acute Type A Aortic Dissection: A Large Retrospective Cohort Study

(1) Background: Deep hypothermic circulatory arrest (DHCA) with selective antegrade cerebral perfusion (ACP) is an established cerebral protection technique for the conduction of complex surgical procedures involving the aortic arch. It is controversial whether the duration of DHCA is associated with adverse outcome in patients with acute type A aortic dissection (AAAD). Our goal was to investigate whether DHCA time was associated with surgical outcome in patients undergoing a surgical treatment of AAAD. (2) Methods: A total of 410 patients were divided into two groups based on the DHCA time less than 60 min and equal to or longer than 60 min. (3) Results: Patients with longer DHCA times were significantly younger (p = 0.001). Intraoperatively, complex procedures with aortic arch surgery were more common in patients with longer DHCA times (p < 0.001). Accordingly, cardiopulmonary bypass (p < 0.001), cross-clamping (p < 0.001) and DHCA times (p < 0.001) were significantly longer in this group. Postoperatively, only the duration of mechanical ventilation (p < 0.001) and the rate of tracheotomy were significantly higher in these patients. Thirty-day mortality was satisfactory for both groups (p = 0.746). (4) Conclusions: Our results showed that improvements in perioperative management including ACP allow for the successful performance of surgical treatment of AAAD under DHCA with a duration of even longer than 60 min.

Subclavian Artery Stenting Under Cerebral Protection by Balloon-Guiding Catheter Inflation Inside the Aortic Arch at the Left Subclavian Artery Origin

We describe a simple and novel technique for cerebral protection during left subclavian artery (SA) stenting by inflation of a balloon-guiding catheter inside the aortic arch at the SA origin. A total of 12 patients with left SA stenosis underwent SA stenting with inflation of a balloon-guiding catheter inside the aortic arch at the left SA origin between January 2020 and December 2020. The SA stenting procedures under proximal protection were retrospectively reviewed to assess ischemic complications, hyperintense spots on diffusion-weighted imaging (DWI), and flow direction of left vertebral artery (VA) during balloon-guiding catheter inflation using ultrasonography (US). The success rate of the SA stenting procedure was 100% with no symptomatic ischemic complications. None of the 12 patients showed small hyperintense spots in DWI. In all patients, the left VA on US during balloon inflation showed retrograde blood flow. The left VA on US had retrograde blood flow during inflation of the balloon-guiding catheter inside the aortic arch at the SA origin. Therefore, the proximal balloon protection inside the aortic arch at the SA origin is a simple and maybe a safe technique for cerebral protection during SA stenting.

Is deep hypothermic circulatory arrest inferior to antegrade cerebral perfusion for brain protection

Objective This study aims to compare the deep hypothermic circulatory arrest (DHCA) and antegrade cerebral perfusion (ACP) with moderate hypothermia for cerebral protection during aortic arch surgery. Background Aortic arch surgery is a complicated technical operation due to the risk of cerebral insults and the need for cerebral protection. Materials and methods Forty patients performed aortic arch surgery with cerebral protection either by, DHCA (18°C) in 20 patients and ACP (22 °C) in the others. Data were collected including; preoperative risks factors, intraoperative finding and postoperative neurological examination and brain computed tomography (CT)when indicated. Results Neurological insults were higher in ACP group (30%) than in DHCA group (10%) without statistical significance. Cardiopulmonary bypass (CPB) time was lower in DHCA group (133.05 ± 28.04) than in ACP group (177.65 ± 53.3), and significantly p-value is ( Conclusion Techniques for cerebral protection (DHCA or ACP)during aortic arch surgery have no statistical significant difference, and each technique has its own advantages and disadvantages.

Influence of moderate hypothermic circulatory arrest on outcome in patients undergoing elective replacement of thoracic aorta.

BackgroundThe ideal technique of cerebral protection in the surgical operation of the ascending aorta.is currently controversial. The current analysis evaluates the influence of moderate hypothermic circulatory arrest (MHCA) on elective replacement of the ascending aorta.MethodsThe study included 905 consecutive patients between 2001 and 2015, who underwent replacement of ascending aorta in MHCA. Patients were divided according to the postoperative 30-day mortality into survivor und non-survivor group.ResultsThe average age was 66.5±11.1 in survivors vs. 70.0±10.5 years in non-survivors (P=0.057). The survivor group had a significantly lower Euro-SCORE II than non-survivors [4.0% (2.3, 6.6) vs. 9.5% (4.8, 20.9); P<0.001)]. The incidence of coronary heart disease (38.0% vs. 58.3%; P=0.022) and chronic renal failure (10.0% vs. 33.3%, P<0.001 was significantly higher in non-survivors. Intraoperatively, the cardiopulmonary bypass time [140 min (112, 185) vs. 194 min (164, 271); P<0.001] and cross-clamping time [91 min (64, 124) vs.119 min (94, 157); P<0.001] were significantly longer in non-survivors. However, the MHCA time was similar in both groups with statistical significance (P=0.023). Postoperatively, re-exploration due to bleeding was highly significant in non-survivors (5.4% vs. 33.3%; P<0.001) with a higher incidence of stroke (4.6% vs. 33.3%; P<0.001). The duration of mechanical ventilation was significantly shorter in survivors than in non-survivors [17 h (12, 26) vs. 147 h (49, 337); P<0.001] with a lower incidence of pulmonary infection (6.0% vs.16.7%; P=0.023). The multivariable logistic regression analysis showed age, female gender, aortic aneurysm, additional CABG, total arch replacement and cardiopulmonary bypass time were independent risk factors for 30-day mortality.ConclusionsThe acceptable morbidity and mortality rates show that MHCA can be considered as a safe technique for cerebral protection in surgical replacement of thoracic aorta.

Cerebral Protection Using Percutaneous Normothermic Bilateral Antegrade Cerebral Perfusion During Total Arch TEVAR in a Patient With Shaggy Aorta

Purpose: To report a technique of global cerebral embolic protection (CEP) designed for use during thoracic endovascular aortic repair (TEVAR). Technique: Arterial cannulas are inserted percutaneously in the right axillary artery (12-F) and left common carotid artery (LCCA; 10-F) to provide normothermic antegrade cerebral perfusion during TEVAR with neuromonitoring. Inferior vena cava blood is drawn using a 19-F femoral cannula, filtered, oxygenated, and delivered through independent roller pumps to the arterial cannulas. Static CEP is obtained by balloon occlusion of the 3 aortic arch branches proximally, resulting in complete separation of aortic and cerebral blood flow; static CEP is used during aortic endograft delivery and deployment. Dynamic CEP, obtained by creating flow reversal in the innominate artery and proximal LCCA, is used at all other times. Successful use of this CEP technique is illustrated in a patient with shaggy aorta undergoing fenestrated total arch TEVAR. Conclusion: Percutaneous normothermic bilateral antegrade cerebral perfusion provides effective CEP during TEVAR.

Factors associated with acute stroke after type A aortic dissection repair: An analysis of the Society of Thoracic Surgeons National Adult Cardiac Surgery Database

ObjectivesData from the Society of Thoracic Surgeons Adult Cardiac Surgery Database was used to examine the incidence and factors associated with acute stroke following type A repair. MethodsAcute type A aortic dissection repairs performed from 2014 to 2017 were identified from the Society of Thoracic Surgeons Adult Cardiac Surgery Database. The effect of cannulation strategy (eg, axillary, femoral, direct, or innominate), lowest temperature, cerebral protection techniques (antegrade cerebral profusion, retrograde cerebral perfusion, both, or none), repair technique, and institutional volume on postoperative stroke was investigated. ResultsAcute type A repair was performed on 8937 patients at 772 centers, of which 7353 met inclusion criteria. Operative mortality was 17% and incidence of postoperative stroke was 13%. Axillary cannulation was associated with lower risk of stroke versus femoral (odds ratio, 0.60; P < .001). Retrograde cerebral perfusion was associated with reduced risk for stroke compared with no cerebral perfusion (odds ratio, 0.75; P = .008) or antegrade cerebral perfusion (odds ratio, 0.75; P = .007). Total arch replacement was associated with greater risk for stroke versus hemiarch technique (odds ratio, 1.30; P = .013). Longer circulatory arrest time, cerebral perfusion time, and cardiopulmonary bypass time were all related to higher risk of postoperative stroke. ConclusionsStroke is a common complication after type A repair. Axillary cannulation was associated with lower incidence of stroke, whereas femoral cannulation significantly increased the risk of stroke regardless of the cerebral perfusion strategy or the degree of hypothermia. Retrograde cerebral profusion was found to have reduced risk for postoperative stroke. Degree of hypothermia and center volume were not related to stroke incidence.

Effects of 4 major brain protection strategies during aortic arch surgery: A protocol for a systematic review and network meta-analysis using Stata.

Background:Reliable brain protection during aortic arch surgery remains a formidable surgical challenge. Various cerebral protection techniques have been used in the clinic; however, there is no consensus regarding which strategy is best. We will perform a network meta-analysis (NMA) focusing on the permanent neurological deficits (PND) and perioperative mortality associated with 4 major brain protection strategies used during aortic arch surgery.Methods:We will perform a literature search of MEDLINE, EMBASE, Cochrane Library, and PubMed databases. The primary outcomes of interest in this analysis will be PND and perioperative mortality. Inconsistencies in the NMA will be evaluated with global and local approaches. Network rank and surface under the cumulative ranking curve (SUCRA) analyses will be performed to evaluate and identify the superiority of different brain protection techniques.Results:This study is ongoing and will be submitted to a peer-reviewed journal for consideration of publication.Conclusions:Our study will increase understanding of 4 major brain protection strategies during aortic arch surgery and be helpful to clinicians using NMA in their studies.

Effect of Retrograde Cerebral Protection Strategy on Outcome of Patients with Stanford Type A Aortic Dissection.

Neurological complications are an important concern in the repair of type A aortic dissection. Supra-aortic involvement is considered to be an important risk factor for neurological injuries. However, the optimal brain protection strategy still remains controversial. The aim of the present study was to assess the efficacy and short-term results of retrograde cerebral protection techniques in the treatment of acute type A aortic dissection. Between 2005 and 2013, 185 patients who underwent repair of acute type A aortic dissection were enrolled in this study, all of whom received retrograde cerebral perfusion. The patients were divided into two group: 102 patients who had at least one carotid artery involved as the carotid dissection group, and 83 patients who had no carotid artery involvement as the non-carotid dissection group. The mean age of the patients was 57.8 years and 69% were male. The 30-day mortality rate was 10.3%, and the overall in-hospital mortality rate was 11.9%. Eight patients (4.3%) developed new permanent neurological deficits (PNDs) including two in the non-carotid dissection group and six in the carotid dissection group. Although new PND was milder in the carotid dissection group, there was no significant difference (p = 0.248). The proportion of patients who received a coronary artery bypass graft was significantly higher in the carotid dissection group (1 vs. 8, p = 0.037). According to our study, the retrograde cerebral perfusion technique is an easy and safe procedure, especially for patients with concomitant carotid dissection.

Simple retrograde cerebral perfusion is as good as complex antegrade cerebral perfusion for hemiarch replacement.

Cerebral complication is a major concern after aortic arch surgery, which may lead to death. Thus, cerebral protection strategy plays the key role to obtain respectable results in aortic arch repair. Deep hypothermic circulatory arrest was introduced in 1970s to decrease the ischemic insults to the brain. However, safe duration of circulatory arrest time was limited to 30 minutes. The 1990s was the decade of evolution for cerebral protection, in which two adjuncts for deep hypothermic circulatory arrest were introduced: retrograde and antegrade cerebral perfusion (ACP) techniques. These two cerebral perfusion techniques significantly decreased incidence of postoperative neurological dysfunction and mortality after aortic arch surgery. Although there are no large prospective studies that demonstrate which perfusion technique provide better outcomes, multiple retrospective studies implicate that ACP may decrease cerebral complications compared to retrograde cerebral perfusion (RCP) when a long circulatory arrest time is required during aortic arch reconstructions. To date, many surgeons favor ACP over RCP during a complex aortic arch repair, such as total arch replacement and hybrid arch replacement. However, the question is whether the use of ACP is necessary during a short, limited circulatory arrest time, such as hemiarch replacement? There is a paucity of data that proves the advantages of a complex ACP over a simple RCP for a short circulatory arrest time. RCP with deep hypothermic circulatory arrest is the simple, efficient cerebral protection technique with minimal interference to the surgical field-and it potentially allows to flush atheromatous debris out from the arch vessels. Thus, it is the preferred adjunct to deep hypothermic circulatory arrest during hemiarch replacement in our institution.

Neurologic Dysfunction after Aortic Dissection Surgery: Different Cerebral Hypothermic Antegrade Perfusion Techniques

Introduction: Neurologic dysfunction remains one of the most disabling complications of emergency aortic arch surgery. Many cerebral protection techniques are described, but their comparison has always been hampered by the wide spectrum of preoperative conditions, pathologic anatomies, complications, and surgical procedures. The aim of our study was to evaluate the incidence of early permanent neurologic injury and in-hospital mortality after emergency aortic arch surgery splitted by different antegrade cerebral perfusion techniques combined with hypothermic circulatory arrest (HCA). Methods: Between January 2005 and December 2015, 249 patients underwent emergent surgery for acute, type A aortic dissection. Of these, 112 (45%) (Mean age 63.8 ± 12.8 years, 82 males) received cerebral protection through antegrade perfusion of the supra-aortic vessels. Unilateral perfusion (UACP) was performed in 55 (49.1%) patients, while bilateral perfusion (BACP) was achieved via right axillary artery cannulation alone in 25 (22.3%) cases or with the Kazui technique in 32 (28.6%). Permanent neurologic injury was defined as the post-operative onset of focal stroke or lethal coma. Results: In-hospital mortality was 17.9% (UACP 20% vs. BACP 15.8%; p=0.56). The global rate of the early permanent neurologic injury was 12.3% (UACP 10.9% vs. BACP 15.8%; p=0.45). Conclusion: There is no evidence that BACP combined with HCA is superior to UACP combined with HCA for emergency aortic arch surgery in preventing early permanent neurologic injury and in-hospital mortality.

Fatal renal and neurological complications after aortic arch repair in newborns

To evaluate effectiveness and safety of various methods of cerebral and visceral protection during aortic arch surgery in infants. Retrospective analysis included 60 patients after aortic arch repair followed by different cerebral protection technique who have been assessed for neurological status and visceral injury in early and long-term postoperative period. Aortic arch surgery with deep hypothermic circulatory arrest for congenital diseases was performed in 26 patients (group 1) and antegrade unilateral selective cerebral perfusion in 34 patients (group 2). Cerebral complications occurred in 28.5% of patients of the 1st group and in 7.9% of patients of the 2nd group. Odds ratio for neurological event is significantly lower in group 2: 0.17 (0.06-0.69; p=0.02). However, there were more patients with renal dysfunction in this group compared with group 1: 58.7% vs. 23.7% (p=0.02).

The Risk of Neurological Dysfunctions after Deep Hypothermic Circulatory Arrest with Retrograde Cerebral Perfusion

Retrograde cerebral perfusion (RCP) is a brain protection technique that is adopted generally for anticipated short periods of deep hypothermic circulatory arrest (DHCA). However, the real impact of this technique on cerebral protection during DHCA remains a controversial issue. For 344 (59.5%) of 578 consecutive patients (mean age, 66.9 ± 10.9 years) who underwent cardiovascular surgery under DHCA at the present authors' institution (1999-2015), RCP was the sole technique of cerebral protection that was adopted in addition to deep hypothermia. Surgery of the thoracic aorta was performed in 95.9% of these RCP patients; in 92 cases there was an aortic arch involvement. Outcomes were reviewed retrospectively. The focus was on postoperative neurological dysfunctions. There were 33 (9.6%) in-hospital deaths. Thirty-one (9%) patients had permanent neurological dysfunctions and 66 (19.1%) transitory neurological dysfunctions alone. Age older than 74 years (odds ratio [OR], 1.88, P = .023), surgery for acute aortic dissection (OR, 2.57; P = .0009), and DHCA time longer than 25 minutes (OR, 2.44; P = .0021) were predictors of neurological dysfunctions. The 10-year nonparametric estimate of freedom from all-cause death was 61.8% (95% confidence interval, 57.8%-65.8%). Permanent postoperative neurological dysfunctions were risk factors for cardiac or cerebrovascular death (hazard ratio, 2.6; P = .039) even after an adjusted survival analysis (P < .04). According to the study findings, RCP, in addition to deep hypothermia, combines with a low risk of neurological dysfunctions provided that DHCA length is 25 minutes or less. Permanent postoperative neurological dysfunctions are predictors of poor late survival.

Hybrid repair of aortic arch aneurysms: a comprehensive review.

Open total arch replacement (TAR) has become safer with refinements in cerebral protection techniques. The frequent extension of aortic arch aneurysms into the descending thoracic aorta customarily requires a two-staged conventional elephant trunk procedure, carrying relatively high mortality and morbidity risks and high rates of rupture in the interval between the two open surgeries. The technical demands and invasive nature of TAR has therefore precluded many high-risk patients from being surgical candidates for aneurysm repair. As a result, hybrid techniques and approaches to the aortic arch have become common since the adoption of thoracic endovascular aortic repair (TEVAR) and advancement in the commercial grafts that are available. The results of hybrid aortic arch repairs have been encouraging, though with higher rates of re-interventions than TAR and variable reported rates of stroke and spinal cord ischemia. The aim of this publication is to review the current literature on hybrid repair of aortic arch aneurysms.

Patient management in aortic arch surgery†.

SummaryAortic arch surgery requires complex patient management beyond the manual replacement of the diseased vessel. These procedures include (i) a thorough and pathologically adjusted preoperative evaluation, (ii) initiation and control of cardiopulmonary bypass, (iii) cerebral protection strategies and (iv) techniques to protect the abdominal end organs during prolonged operations. Due to the complexity of aortic arch procedures, multimodal real-time surveillance is required during all stages of the operation. Although having the patient survive the operation is the major goal, further observation is necessary because of the chronicity of the disease. This review summarizes specific aspects of patient management during and after operations requiring periods of circulatory arrest, without necessarily referring to all studies on this topic. The pros and cons of different strategies are weighed against each other, including the personal experience of the authors. A number of questions are raised without providing a 'right' or 'wrong' answer. We show that a number of different well-established strategies can result in comparable excellent long-lasting surgical results.