Search

Objectives: Antegrade cerebral perfusion (ACP) under moderate hypothermic circulatory arrest is used during total aortic arch replacement surgery (TARS) in patients with acute type A aortic dissection, but it is associated with high mortality and morbidity. We hypothesized that combining ACP with retrograde inferior vena caval perfusion (RIVP) improves outcomes., Methods: This pilot study was prospective, randomized, controlled and assessor-blinded. Patients scheduled for TARS were randomly treated with either ACP or RIVP + ACP. The primary outcome was a composite of mortality and major complications including paraplegia, postoperative renal failure, severe liver dysfunction, and gastrointestinal complications. Secondary outcomes included neurological complications, length of intubation and requirement of blood products., Results: A total of 76 patients were recruited (n = 38 per group). Primary outcome occurred in 23 patients (61%) in the ACP group and 16 (42%) in the RIVP + ACP group (OR: 0.60, 95% CI: 0.21-1.62; p = 0.31). There was a lower incidence of transient neurological deficits in the RIVP + ACP group (26% vs. 58%, OR: 0.26; 95% CI: 0.10-0.67,p = 0.006;). The RIVP + ACP group underwent shorter intubation (25 vs 47 h, p = 0.022) and required fewer blood products (red cells, 3.8 units vs 6.5 units, p = 0.047; platelet: 2.0 units vs 2.0 units, p = 0.023) compared with the ACP group., Conclusions: RIVP + ACP may be associated with lower incidence of transient neurological deficits, shorter intubation and less blood transfusion requirement than ACP alone during TARS. Multi-center, randomized trials with larger samples are required to determine whether RIVP + ACP is associated with lower rates of mortality and major complications., Trial Registration: Pilot study of a RCT registered in clinicaltrials.gov (NCT03607786), Registered 30 July, 2018-Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03607786 .

Background: During total aortic arch replacement surgery (TARS) for patients with acute type A aortic dissection, the organs in the lower body, such as the viscera and spinal cord, are at risk of ischemia even when antegrade cerebral perfusion (ACP) is performed. Combining ACP with retrograde inferior vena caval perfusion (RIVP) during TARS may improve outcomes by providing the lower body with oxygenated blood., Methods: This study is designed as a multicenter, computer-generated, randomized controlled, assessor-blind, parallel-group study with a superiority framework in patients scheduled for TARS. A total of 636 patients will be randomized on a 1:1 basis to a moderate hypothermia circulatory arrest (MHCA) group, which will receive selective ACP with moderate hypothermia during TARS; or to an RIVP group, which will receive the combination of RIVP and selective ACP under moderate hypothermia during TARS. The primary outcome will be a composite of early mortality and major complications, including paraplegia, postoperative renal failure, severe liver dysfunction, and gastrointestinal complications. All patients will be analyzed according to the intention-to-treat protocol., Discussion: This study aims to assess whether RIVP combined with ACP leads to superior outcomes than ACP alone for patients undergoing TARS under moderate hypothermia. This study seeks to provide high-quality evidence for RIVP to be used in patients with acute type A aortic dissection undergoing TARS., Trial Registration: Clinicaltrials.gov, ID: NCT03607786 . Registered on 30 July 2018.

Background: To analyze utilization of a perfusion branch for temporary sac perfusion to reduce the spinal cord ischemia (SCI) in the endovascular repair of thoracoabdominal aortic aneurysms (TAAAs)., Methods: Between January 2012 and August 2016, 30 patients (18, men; median age 72 years) were treated for TAAAs with total endovascular repair using customized branched/fenestrated endografts in our institution. The median aneurysm size was 6.6 cm. Types of TAAA were: type I, 9 (30%), type II, 5 (16.6%), type III, 4 (13.3%), type IV, 6 (20%), and type V, 6 (20%). Ten patients received a perfusion branch to create an intentional endoleak, which was occluded with vascular plugs in mean interval time of 8.2 weeks (range: 6-10). Staged procedure and automated cerebrospinal fluid drainage were used in 23 (77%) and 24 (80%) patients, respectively., Results: The technical success was 97%; 107 renovisceral target vessels were revascularized (32 fenestrations, 75 branches). At the time of the planned reinterventions, the mean arterial pressure (MAP) gradients were measured between the temporarily perfused aneurysm sac and the aortic endografts, and they were significantly higher (mean gradients 42.5 ± 10 mm Hg; range: 30-60) within the aortic grafts. The in-hospital and 30-day mortality was 3.3%. The incidence of postoperative SCI was 3/20 (15%) in the standard group and 0% in the group of the perfusion branch ( p  = 0.28). The mean follow-up was 12 months (range: 2-51)., Conclusion: We experience that the use of a dedicated perfusion branch is feasible and may serve as protective adjunct to reduce the risk of SCI in endovascular treatment of TAAA. The risk of rupture in interval appears to be low. Larger series and multicenter studies are warranted to corroborate these results., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Georg Thieme Verlag KG Stuttgart · New York.)

Objective: We describe an alternate technique for establishing antegrade cerebral perfusion (ACP) during hypothermic circulatory arrest via direct, central cannulation of the innominate artery., Methods: From 2009 to 2015, 100 elective hemiarch reconstructions for proximal aortic aneurysms were performed under moderate hypothermic circulatory arrest (MHCA). Cerebral perfusion was instituted with ACP via direct cannulation of the innominate artery., Results: Mean patient age was 63 ± 13 years (72 men; 72%). Mean MHCA temperature was 27.3°C ± 1.0°C (median, 28°C). Mean ACP time was 17 ± 4 minutes and mean crossclamp time was 134 ± 42 minutes. Proximal reconstruction included root replacement with composite valved graft (n = 47), valve sparing root reimplantation (n = 16), and aortic valve replacement (n = 19). In-hospital 30-day mortality (n = 1; 1%), stroke (1; 1%), reversible ischemic neurologic deficit (n = 1; 1%), coma (n = 0), and renal failure (n = 1; 1%) rates were low. There was no incidence of injury or dissection of the innominate artery., Conclusions: Direct, central innominate artery cannulation for ACP yields excellent outcomes. This technique is safe, provides excellent cerebral protection during circulatory arrest and simplifies the circulatory management strategy for elective ascending aortic and hemiarch reconstruction., (Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Acute renal failure (ARF) is reported in up to 12% of patients after thoracoabdominal aortic aneurysm (TAAA) repair with assisted circulation. ARF increases mortality, reduces quality of life, and increases length of hospital stay. This study analyzes ARF after TAAA repair done without assisted circulation., Methods: A retrospective analysis of all patients treated for TAAA from 2000 to 2013 was performed using a concurrently maintained, institutionally approved database. All surgeries used simple cross-clamp technique, with moderate systemic hypothermia (32°-33°C) and renal artery perfusion with 4°C solution. Serum creatinine concentration was measured preoperatively and 1 day, 3 days, 7 days, and 30 days after surgery, and Cockcroft-Gault estimated glomerular filtration rate (eGFR) was calculated. Kidney injury was classified by RIFLE (Risk, Injury, Failure, Loss of kidney function, End-stage renal disease) eGFR criteria. Changes in eGFR, kidney injury, ARF, dialysis, length of stay, mortality, and risk factors for ARF were analyzed with SAS-JMP software (SAS Institute, Cary, NC) for univariate analysis and multivariate modeling., Results: From 2000 to 2013, 455 patients had TAAA surgery; 116 (25.5%) were acute. Mean preoperative eGFR was 62.3 mL/min. Mean renal ischemia time was 58.9 minutes. Eighteen patients (4%) had ARF; nine (2%) required temporary dialysis, and three (0.66%) required permanent dialysis. In univariate analysis, age, renal ischemia time, acuity, baseline eGFR, previous aortic surgery, surgical blood loss, and return to operating room for bleeding complications were significant for ARF (P < .05). Sex, aneurysm extent by Crawford type, cardiac index and mean arterial pressure after reperfusion, and use of loop diuretics were not significant for ARF. In a stepwise deletion model, acute (P = .0377), previous aortic surgery (P = .0167), return to operating room (P = .0213), and age (P = .0478) were significant for ARF. Surgical blood loss (P = .0056) and return to operating room (P = .0024) were significant for postoperative dialysis in multivariate analysis. Only surgical blood loss was significant for permanent dialysis in a multivariate model (P = .0331)., Conclusions: Very low ARF after TAAA repair can be achieved by simple cross-clamp technique with moderate systemic hypothermia and profound renal cooling. Age, preoperative eGFR, previous aortic surgery, return to operating room, and surgical blood loss were significant for ARF. Return to operating room for bleeding and surgical blood loss were significant for dialysis. Baseline eGFR <30 mL/min and postoperative dialysis were significant for mortality. Most patients with ARF, even those with temporary dialysis after TAAA repair, recover renal function to near preoperative levels., (Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: Antegrade cerebral perfusion and hypothermic circulatory arrest, with or without retrograde cerebral perfusion, are 2 major types of brain protection that are used during aortic arch surgery. We conducted a comparative study of these methods in patients undergoing total arch replacement to evaluate the clinical outcomes in Japan, based on the Japan Adult Cardiovascular Surgery Database., Methods: A total of 16,218 patients underwent total arch replacement between 2009 and 2012. Patients with acute aortic dissection or ruptured aneurysm, or who underwent emergency surgery were excluded, leaving 8169 patients for analysis. For the brain protection method, 7038 patients had antegrade cerebral perfusion and 1141 patients had hypothermic circulatory arrest/retrograde cerebral perfusion. A nonmatched comparison was made between the 2 groups, and propensity score analysis was performed among 1141 patients., Results: The matched paired analysis showed that the minimum rectal temperature was lower in the hypothermic circulatory arrest/retrograde cerebral perfusion group (21.2°C ± 3.7°C vs 24.2°C ± 3.2°C) and that the duration of cardiopulmonary bypass and cardiac ischemia was longer in the antegrade cerebral perfusion group. There were no significant differences between the antegrade cerebral perfusion and hypothermic circulatory arrest/retrograde cerebral perfusion groups with regard to 30-day mortality (3.2% vs 4.0%), hospital mortality (6.0% vs 7.1%), incidence of stroke (6.7% vs 8.6%), or transient neurologic disorder (4.1% vs 4.4%). There was no difference in a composite outcome of hospital death, bleeding, prolonged ventilation, need for dialysis, stroke, and infection (antegrade cerebral perfusion 28.4% vs hypothermic circulatory arrest 30.1%). However, hypothermic circulatory arrest/retrograde cerebral perfusion resulted in a significantly higher rate of prolonged stay in the intensive care unit (>8 days: 24.2% vs 15.6%)., Conclusions: Hypothermic circulatory arrest/retrograde cerebral perfusion and antegrade cerebral perfusion provide comparable clinical outcomes with regard to mortality and stroke rates, but hypothermic circulatory arrest/retrograde cerebral perfusion resulted in a higher incidence of prolonged intensive care unit stay. Antegrade cerebral perfusion might be preferred as the brain protection method for complicated aortic arch procedures., (Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: Previous studies have reported a high incidence of acute kidney injury (AKI) after thoracic aortic surgery. However, the incidence of AKI in patients undergoing total arch replacement (TAR) with selective cerebral perfusion (SCP) and mild hypothermic lower body circulatory arrest (mild HLBCA) with a tympanic temperature of 25°C remains unknown. We studied AKI incidence and associated risk factors, as defined by the Acute Kidney Injury Network (AKIN)., Methods: We examined 116 consecutive patients with aortic arch aneurysm undergoing non-emergency TAR. Our surgical method is standardized to use systemic cooling of the tympanic membrane temperature to 25°C for circulatory arrest, followed by SCP and myocardial protection by cold blood cardioplegia. Anastomoses were sequentially constructed at the distal arch, the proximal root, the left sub-clavian artery, the left carotid artery and the right brachiocephalic artery. Bladder temperature was generally around 30°C at the start of lower body circulatory arrest (mild HLBCA) until reperfusion of the distal aorta. The incidence of AKI was investigated, with multivariate analysis of its risk factors., Results: The mean operation time, cardiopulmonary bypass (CPB) time, mild HLBCA time and SCP time were 270.6 ± 72.5, 151.0 ± 46.4, 53.1 ± 20.1 and 99.0 ± 28.4 min, respectively. Hospital mortality occurred in 2 cases (1.7%). AKI occurred in 50 cases (43.1%); of which, 2 cases required renal replacement therapy (RRT). However, AKI had subsided in 44 cases by discharge. For contemporary perspective, the incidence of AKI was 32.8% in off-pump coronary bypass grafting and 38.9% in aortic valve replacement. Multivariate analysis of risk factors for AKI identified chronic kidney disease (CKD) (eGFR <60 ml/min/1.73 m(2)) and mild HLBCA time >60 min., Conclusions: Our method of TAR was associated with low mortality and low rate of kidney injury by discharge. However, prolonged mild HLBCA and preoperative CKD might need additional consideration., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Open thoracoabdominal aortic aneurysm (TAAA) repair traditionally carries substantial perioperative morbidity and mortality, primarily from distal aortic ischemia. Advances in surgical techniques, adjuncts, and strategies have greatly improved outcomes., Methods: We analyzed outcomes of 1267 open consecutive TAAA repairs between January 2005 and September 2013. We provided cold crystalloid renal perfusion whenever the renal ostia were accessible; according to extent of repair, we selectively used left heart bypass and provided isothermic blood to the celiac axis and superior mesenteric artery. Repair was extensive (Crawford extent I and II) in 717 cases (57%). Left heart bypass was used in 645 (51%) cases, cold crystalloid renal perfusion in 987 (78%), and isothermic visceral perfusion in 318 (25%). Additional patient-specific surgical adjuncts included endarterectomy of renal or visceral vessels, open stent placement within these vessels, or use of both techniques; at least one was used in 447 repairs (35%)., Results: Thirty-day survival was 95% (1198/1267); overall operative mortality was 8% (104/1267). Acute renal dysfunction occurred in 155 (12%), renal failure requiring hemodialysis at hospital discharge in 84 (7%), and bowel ischemia in 9 (<1%). Extent II and III TAAA repairs carried the highest risks of postoperative renal dysfunction and renal failure requiring hemodialysis at hospital discharge., Conclusions: Contemporary protective strategies allow open TAAA repair with substantially fewer renal and visceral ischemic complications. Although bowel ischemia is uncommon, renal failure remains a concern, especially in extent II and extent III TAAA repairs. Additional studies are needed to identify and improve renal protection strategies., (Copyright © 2014. Published by Elsevier Inc.)

Objective: The choice of cerebral perfusion strategy for aortic arch surgery has been debated, and the superiority of antegrade (ACP) or retrograde (RCP) cerebral perfusion has not been shown. We examined the early and late outcomes for ACP versus RCP in proximal (hemi-) arch replacement using deep hypothermic circulatory arrest (DHCA)., Methods: A retrospective analysis of a prospectively maintained database was performed for all patients undergoing elective and nonelective hemiarch replacement at a single referral institution from June 2005 to February 2013. Total arch cases were excluded to limit the analysis to shorter DHCA times and a more uniform patient population for whom clinical equipoise regarding ACP versus RCP exists. A total of 440 procedures were identified, with 360 (82%) using ACP and 80 (18%) using RCP. The endpoints included 30-day/in-hospital and late outcomes. A propensity score with 1:1 matching of 40 pre- and intraoperative variables was used to adjust for differences between the 2 groups., Results: All 80 RCP patients were propensity matched to a cohort of 80 similar ACP patients. The pre- and intraoperative characteristics were not significantly different between the 2 groups after matching. No differences were found in 30-day/in-hospital mortality or morbidity outcomes. The only significant difference between the 2 groups was a shorter mean operative time in the RCP cohort (P = .01). No significant differences were noted in late survival (P = .90)., Conclusions: In proximal arch operations using DHCA, equivalent early and late outcomes can be achieved with RCP and ACP, although the mean operative time is significantly less with RCP, likely owing to avoidance of axillary cannulation. Questions remain regarding comparative outcomes with straight DHCA and lesser degrees of hypothermia., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To examine the clinical outcomes and impact of using moderate hypothermic circulatory arrest (MHCA) and unilateral selective antegrade cerebral perfusion (uSACP) in the setting of total aortic arch replacement (TOTAL)., Methods: From 2004 to 2012, 733 patients underwent open arch reconstruction with MHCA and SACP. Of these, 145 (20%) underwent TOTAL. Measured outcomes included death, stroke, temporary neurologic dysfunction (TND), and renal failure. Mean follow-up time was 33 months and ranged from 0 to 95 months., Results: Core temperature at the onset of MHCA was 25.8°C. Cardiopulmonary bypass and myocardial ischemic times were 236 minutes and 181 minutes, respectively. Twenty-three patients (16%) underwent emergency repair of acute type A dissection. Fifty-four cases (37%) were reoperative and 52 (34%) were stage I elephant trunk procedures. Concomitant root replacement was performed in 50 (35%) patients, including 20 David V valve-sparing procedures. Mean duration of circulatory arrest was 55 minutes. Operative mortality was 9.7%. Overall incidence of stroke and TND was 2.8% and 5.6%, respectively. Four patients (2.8%) required postoperative dialysis. Seven-year survival was significantly reduced (P = .04) after repair of type A dissection (83.8%) compared with elective surgery (89.5%). Higher temperature during TOTAL was not found to be a significant risk factor for adverse events., Conclusions: TOTAL using MHCA and uSACP can be accomplished with excellent early and late results. MHCA was not associated with adverse neurologic outcomes or higher operative risk, despite prolonged periods of circulatory arrest., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Prior studies indicated improved early mortality and paraplegia rates in a small cohort of patients with type I-III thoracoabdominal aortic aneurysms (TAAs) treated with atriofemoral bypass (AFB) and motor-evoked potentials (MEVPs) when compared with a propensity-matched cohort of patients treated with the clamp and sew (CS) method, wherein epidural cooling was the principal spinal cord protective adjunct. The use of AFB/MEVP increases the complexity of TAA repair and in this study, we address whether the early benefits will be sustained when this is applied to a general population with type I-III TAAs., Methods: Consecutive patients undergoing repair of nonruptured Crawford extent I-III TAAs from 1/1987 to 12/2011 were identified. Patients were stratified according to operative approach (AFB/MEVP vs CS). Endpoints included long-term survival, and the composite outcome of perioperative death and paraplegia. A multivariate, risk-adjusted model was then created to determine if operative approach independently influenced outcome., Results: There were 485 patients (CS = 385 [79%]; AFB/MEVP = 100 [21%]). The cohorts differed in that the AFB/MEVP group was younger (65.8 ± 12.5 years vs 70.9 ± 9.7 years; P < .001), had more extent I/II aneurysms (66% vs 50.1%; P = .005), and had more chronic dissections (30.3% vs 18.9%; P = .018). Operative variables differed in that the AFB/MEVP cohort had longer operative times (434 ± 112 minutes vs 324 ± 98 minutes; P < .001) and higher blood turnover (6028 ± 3473 mL vs 3581 ± 3111 mL; P < .0001). There was no difference in the rate of intraoperative death (AFB/MEVP = 1.0% vs CS = 0.5%; P = .50), length of intensive care unit stay (AFB/MEVP = 9.6 ± 8.6 days vs CS = 9.5 ± 12.3 days; P = .95) or hospital length of stay (AFB/MEVP = 19.9 ± 12.6 days vs CS = 21.6 ± 23.5 days; P = .49). The composite perioperative death and paraplegia rate was lower in the AFB/MEVP cohort (7% vs 19%; P = .004). The multivariate model for predictors of the composite outcome showed that AFB/MEVP was protective (odds ratio, 0.39; 95% confidence interval, 0.17-0.9; P = .028). Long-term (4-year) survival was improved in the AFB/MEVP group as well (73 ± 6% vs 60 ± 3%; P = .004)., Conclusions: AFB/MEVP is an independent predictor of improved perioperative death and paraplegia rates as well as long-term survival in patients undergoing repair of type I-III TAAs and is the preferred operative strategy., (Copyright © 2013 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Femoro-femoral veno-arterial perfusion is an established circulatory support and cooling method for thoracic- and/or thoracoabdominal aortic aneurysm repair. However, retrograde perfusion through femoral arteries can lead to retrograde cerebral embolization and neurologic dysfunction after surgery. To avoid these complications, we have established a femoro-femoral veno-venous perfusion technique and evaluated its safety and effectiveness in elective and nonelective patients., Methods: Common femoral veins were cannulated bilaterally percutaneously following systemic low-dose heparinization (100 IU/kg body weight). Venous blood was drained from drainage of the inferior vena cava, and venous return followed through the superior vena cava. After proximal aortic cross-clamping, veno-venous perfusion was switched to veno-arterial antegrade perfusion through the distal descending thoracic aorta to achieve spinal and visceral perfusion or through iliac arteries for distal perfusion combined with selective renovisceral blood perfusion. After completion of aortic repair, the arterial cannula was removed and the patient rewarmed just by switching back to veno-venous perfusion. Gas and temperature exchange as well as relevant hemodynamic parameters were recorded prospectively and analyzed retrospectively in 25 consecutive patients including 15 nonelective cases., Results: Percutaneous insertion of outflow (28F cannula) and inflow (18F cannula) venous cannulae was complication-free and allowed unrestricted perfusion in all 25 patients. Veno-venous perfusion allowed effective cooling (mean body temperature 36.6 ± 0.6°C to 31.6 ± 2.1°C, P = .001 compared with start of cooling) and re-warming (mean body temperature 30.5 ± 3°C to 36.3 ± 0.8°C, P = .03 compared with start of re-warming). Hemodynamic as well as pulmonary parameters remained remarkably stable during surgical dissection and single lung ventilation even in nonelective cases. There was no complication associated with the perfusion technique during surgery., Conclusions: Transfemoral veno-venous cooling and re-warming results in remarkable hemodynamic stability during open repair of thoracic- and/or thoracoabdominal aortic aneurysms and eliminates the need for retrograde arterial perfusion and its inherent risks., (Copyright © 2013 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: To evaluate the effectiveness of innominate artery cannulation in proximal aortic procedures, including those involving hypothermic circulatory arrest., Methods: A total of 68 patients underwent innominate artery cannulation with a side graft during proximal aortic surgery performed by way of a median sternotomy. The indications for surgery were proximal arch aneurysm in 43 patients (63.2%), aortic dissection in 11 patients (16.2%), total arch aneurysm in 10 patients (14.7%), and ascending aortic aneurysm in 4 patients (5.9%). Six patients (8.8%) had undergone previous sternotomy. Hypothermic circulatory arrest with antegrade cerebral perfusion was used in 64 patients (94.1%). Of the 68 patients, 63 (92.6%) received antegrade cerebral perfusion to both cerebral hemispheres. The median antegrade cerebral perfusion time was 20 minutes (range, 15.0-33.0 minutes). Seven patients had periods of circulatory arrest without antegrade cerebral perfusion for a median of 20 minutes (range, 6-33 minutes)., Results: One patient died, for 30-day mortality of 1.5%. Three patients (4.4%) had strokes, two of whom had a partial recovery. Seven patients (10.3%) developed temporary postoperative confusion that resolved successfully in all cases., Conclusions: Cannulating the innominate artery for arterial inflow is an alternative technique for proximal aortic surgery procedures. It is especially useful in cases requiring hypothermic circulatory arrest to deliver antegrade cerebral perfusion., (Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Surgery of the ascending aorta and aortic arch has been challenging since its inception as neurological complications may occur significantly affecting the quality of life (QOL)., Methods:  From January 1998 to December 2007, 79 patients mainly suffering aortic dissection (65%) or true aortic aneurysm (34%) underwent surgery on the aortic arch employing deep hypothermic circulatory arrest and selective antegrade cerebral perfusion. QOL was assessed with the sickness-impact-profile (SIP) comprising 136 questions and 12 categories., Results: All patients underwent replacement of the ascending aorta, combined with a partial (hemiarch) (n = 33; 42%) or total (n = 46, 58%) arch replacement. Thirty-day mortality was 17.7% (n = 14 patients). Perioperatively, three patients (3.8%) suffered a transitory ischemic attack (TIA) and 5.1% patients suffered a stroke. The median score of the complete questionnaire was 4.7, which demonstrates excellent QOL following such complex surgical procedures. The median physical dimension was 2.5 (0; 8), the psychosocial median score was 3.7 (1.2; 16.1), both underline an only minimal impairment of the daily life., Conclusion:  The QOL after following the surgery of ascending aorta and aortic arch with selective antegrade cerebral perfusion is excellent on the long-term as assessed by the SIP., (Georg Thieme Verlag KG Stuttgart · New York.)

Objective: Total arch replacement has been reported to present high morbidity and mortality. We have introduced a stepwise distal anastomosis technique and modified perfusion strategy, including selective antegrade cerebral perfusion, moderate hypothermia, and separate lower-body perfusion, to minimize organ ischemia and secondary morbidities. We report the operative outcomes of total arch replacement with our modified perfusion strategy., Methods: Between August 2006 and December 2008, 119 patients underwent total arch replacement with the current perfusion strategy. Of these patients, 56 (47%) underwent emergency operation for acute type A aortic dissection (n = 48) or ruptured thoracic aneurysm (n = 8). The mean age of patients was 68 years, and the mean follow-up period was 25 months. We analyzed operative mortality, morbidity, and 4-year survival of this patient group., Results: The mean operation, cardiopulmonary bypass, and circulatory arrest times were 313, 183, and 47 minutes, respectively. Operative mortality was 3.4%. Operative mortality of elective cases was 1.6%. The incidences of permanent neurologic deficit, paraparesis, and renal insufficiency were 5.0%, 1.7%, and 7.6%, respectively. Actuarial 4-year survival was 86.5%., Conclusions: Total arch replacement with our modified perfusion strategy has demonstrated low operative mortality and morbidity., (Copyright © 2012 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Thoracoabdominal aortic aneurysms (TAAA) and extensive thoracic descending aortic aneurysms (TDA) are not accessible through standard endovascular treatment. Fenestrated and branched endograft technology was developed rapidly without widespread application. The aim of this study was to review our open repair (OR) experience of TAAA and TDA. A total of 28 patients who underwent elective OR of TAAA or TDA between January 2001 and January 2009 were analyzed retrospectively. The mean age of the patients was 65.5 years (three women). The anatomic locations of the aneurysms were as follows: six in thoracic descending aorta and 22 in thoracoabdominal aorta (14 TAAA I, two TAAA II, six TAAA III). TDA (40 patients) available for ordinary endovascular treatment and TAAA IV (35 patients) were excluded from this study. To focus on spinal cord vascularization, 25 patients were submitted for angiography. Three patients suffering from back pain required quick treatment and were excluded from angiographic investigations. Angiography procedures were contributive in 23 patients (92%). Surgical repairs were driven through left thoraco-phreno-laparotomy, with the adjunct of distal aortic perfusion (femorofemoral bypass) including the use of an oxygenator and sequential aortic cross-clamping. Cerebrospinal fluid drainage was not used in this experience. The 30-day mortality rate was 14.3% (four of 28 patients): one multiorgan failure and three pulmonary sepsis. An immediate postoperative paraplegia occurred, affecting a patient with TDA who was previously submitted for infrarenal aorta replacement, despite angiographic identification and revascularization of intercostal artery destined to spinal artery. The 1-year survival rate was 82.1% (23 of 28 patients). In the preliminary experience of this study, OR of extensive TAAA and TDA with distal aortic perfusion and an oxygenator without use of cerebrospinal fluid drainage was associated with a significant perioperative mortality rate (14.2%), a reasonable rate of paraplegia (3%), and 1-year survival rate of 82.1%., (Copyright © 2011 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)

Objective: It is reported that hypothermia has some protective effect against ischemia of the spinal cord during thoracoabdominal aneurysm repair. However, it has not been elucidated clinically whether regional spinal cord hypothermia by epidural perfusion cooling is effective and safe. The purpose of this study was to assess the effect and safety of perfusion cooling of the epidural space during most or all of descending thoracic or thoracoabdominal aneurysm repair., Methods: From January 1998 to December 2007, a total of 102 patients with a mean age of 61 years underwent replacement of most or all of the descending thoracic aorta or thoracoabdominal aorta with the aid of mild hypothermia via epidural perfusion cooling and cerebrospinal fluid (CSF) drainage. Risk factors for spinal cord injury and hospital death were analyzed using univariate and multivariate analyses. The actuarial survival rate was calculated by the Kaplan-Meier method., Results: The mean lowest CSF temperature was 23.3 degrees C during epidural perfusion cooling. The mean temperature difference between the nasopharynx and CSF was 8.4 degrees C. The incidence of spinal cord injury was 3.9% (4/102), and that of hospital death was 5.9% (6/102). There was no significant risk factor associated with spinal cord injury. Type III aneurysm and postoperative cerebrovascular accident, respiratory failure, liver failure, and infection were predictors of hospital death. The actuarial survival rates at 3 and 5 years were 82.1% and 75.9%, respectively., Conclusion: Epidural perfusion cooling is a safe method to employ in clinical situations. Our contemporary management strategies enabled patients to undergo thoracoabdominal aneurysm repair with excellent early and late survival and acceptable morbidity.

The authors used profound hypothermic circulatory arrest and continuous retrograde cerebral perfusion for aortic surgery that involved the distal arch through a left thoracotomy. For the first seven patients, oxygenated blood from cardiopulmonary bypass was perfused retrogradely through a venous cannula positioned into the right atrium. In the last 11 cases, venous blood, provided by a perfusion from the lower body, was circulated passively in the brain with the descending aorta clamped. The period of profound hypothermic circulatory arrest was 34.6 +/- 11.1 min, and continuous retrograde cerebral perfusion was 31.3 +/- 11.1 min. Seventeen patients survived, but there was one early death. Two patients with a severely atherosclerotic aneurysm developed permanent neurological dysfunction. The combination of profound hypothermic circulatory arrest, continuous retrograde cerebral perfusion and open aortic anastomosis through a left thoracotomy protects the brain adequately, and facilitates evacuation of debris and air in the aortic arch. It produces satisfactory results for aortic surgery that involves the distal arch.