Technical advances in total aortic arch replacement

BACKGROUND: We compared the effects of using hypothermic circulatory arrest (HCA) alone, HCA combined with selective cerebral perfusion (SCP), and use of SCP with a trifurcated graft (T) on outcome after aortic arch repair. METHODS: One hundred fifty patients, median age 66 years (range, 27 to 85), underwent total arch replacement between 1988 and 2002; 75 were female. We retrospectively compared the results of three patient groups roughly comparable with regard to preoperative risk factors: 45 patients using HCA beginning in 1988; 67 patients using HCA/SCP beginning in 1994; and 38 patients utilizing a trifurcated arch graft in conjunction with SCP through the axillary artery (HCA/SCP/T) since 2000. The groups were well matched with regard to median age (66, 68, and 66 years), urgency (emergent 11%, 13%, 5%; urgent 24%, 9%, 18%; and elective 64%, 78%, 76%), and several other known risk factors (p = not significant). RESULTS: An adverse outcome-hospital death or permanent stroke-occurred in 14%: in 16% with HCA, in 16% with HCA/SCP, and in 8% with HCA/SCP/T. Transient neurologic dysfunction among patients surviving without stroke was lower with HCA/SCP/T (11%) than with HCA (33%) or HCA/SCP (17%). Mean duration of HCA was 52 +/- 16 minutes with HCA alone versus 45 +/- 10 minutes with HCA/SCP and 31 +/- 7 minutes with HCA/SCP/T (p < 0.0001 for groups HCA and HCA/SCP combined versus HCA/SCP/T). Mean duration of SCP was 57 +/- 25 minutes with HCA/SCP versus 62 +/- 24 minutes with HCA/SCP/T (p = not significant). Comparison of the groups of patients who had comparable preoperative risk factors for adverse outcome showed a trend toward lower adverse outcome and transient neurologic dysfunction rates using HCA/SCP/T; a significant reduction in respiratory (p < 0.001), infectious (p = 0.015) and cardiac (p = 0.005) complications in HCA/SCP/T compared with the earlier groups; and significantly shorter durations of intensive care (p < 0.0001) and hospitalization (p = 0.004). CONCLUSIONS: Our results suggest that HCA/SCP is superior to HCA alone for preventing cerebral injury during operations on the aortic arch. By further reducing embolic risk as well as duration of HCA, HCA/SCP/T with axillary artery cannulation may be the optimal technique for averting adverse outcomes, reducing complications, and shortening hospital stay after aortic arch repair.