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With advances in modern day imaging techniques for the aorta, there has been an increasing incidence of vascular diseases involving the aortic arch. Historically, the only treatment option for arch disease has been open arch replacement under circulatory arrest conditions with or without selective cerebral perfusion. However, this open procedure has significant morbidity and mortality, especially in elderly patients with multiple comorbidities. To potentially mitigate the risks associated with open replacement, endovascular arch repair has gained momentum as an alternative treatment option. Currently, aortic arch stenting is being trialed in multiple international medical centers across Europe and the United States. The outcomes data available thus far are promising, which suggest that there likely will be an increase in patients being referred for aortic arch stenting procedures in the future. In this emerging technology review, multiple aspects of the aortic arch stenting procedure are discussed including the currently available endovascular arch devices, the unique surgical and anesthetic considerations for arch stent implantation, and the early outcomes data published to date.

Importance Intraoperative electroencephalogram (EEG) waveform suppression, often suggesting excessive general anesthesia, has been associated with postoperative delirium. Objective To assess whether EEG-guided anesthetic administration decreases the incidence of postoperative delirium. Design, Setting, and Participants Randomized clinical trial of 1232 adults aged 60 years and older undergoing major surgery and receiving general anesthesia at Barnes-Jewish Hospital in St Louis. Recruitment was from January 2015 to May 2018, with follow-up until July 2018. Interventions Patients were randomized 1:1 (stratified by cardiac vs noncardiac surgery and positive vs negative recent fall history) to receive EEG-guided anesthetic administration (n = 614) or usual anesthetic care (n = 618). Main Outcomes and Measures The primary outcome was incident delirium during postoperative days 1 through 5. Intraoperative measures included anesthetic concentration, EEG suppression, and hypotension. Adverse events included undesirable intraoperative movement, intraoperative awareness with recall, postoperative nausea and vomiting, medical complications, and death. Results Of the 1232 randomized patients (median age, 69 years [range, 60 to 95]; 563 women [45.7%]), 1213 (98.5%) were assessed for the primary outcome. Delirium during postoperative days 1 to 5 occurred in 157 of 604 patients (26.0%) in the guided group and 140 of 609 patients (23.0%) in the usual care group (difference, 3.0% [95% CI, −2.0% to 8.0%];P = .22). Median end-tidal volatile anesthetic concentration was significantly lower in the guided group than the usual care group (0.69 vs 0.80 minimum alveolar concentration; difference, −0.11 [95% CI, −0.13 to −0.10), and median cumulative time with EEG suppression was significantly less (7 vs 13 minutes; difference, −6.0 [95% CI, −9.9 to −2.1]). There was no significant difference between groups in the median cumulative time with mean arterial pressure below 60 mm Hg (7 vs 7 minutes; difference, 0.0 [95% CI, −1.7 to 1.7]). Undesirable movement occurred in 137 patients (22.3%) in the guided and 95 (15.4%) in the usual care group. No patients reported intraoperative awareness. Postoperative nausea and vomiting was reported in 48 patients (7.8%) in the guided and 55 patients (8.9%) in the usual care group. Serious adverse events were reported in 124 patients (20.2%) in the guided and 130 (21.0%) in the usual care group. Within 30 days of surgery, 4 patients (0.65%) in the guided group and 19 (3.07%) in the usual care group died. Conclusions and Relevance Among older adults undergoing major surgery, EEG-guided anesthetic administration, compared with usual care, did not decrease the incidence of postoperative delirium. This finding does not support the use of EEG-guided anesthetic administration for this indication. Trial Registration ClinicalTrials.gov Identifier:NCT02241655

Background: Intraoperative electroencephalogram suppression, suggesting excessive general anaesthesia, predicts postoperative delirium. The primary purpose of this trial was to assess the effectiveness of electroencephalography-guided minimisation of anaesthetic administration and electroencephalogram suppression to prevent postoperative delirium in older adults. Methods: The Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes [ENGAGES] study enrolled adults older than 60 undergoing major surgery under general anaesthesia at Barnes-Jewish Hospital in Saint Louis. Using a computer-generated randomisation sequence we randomly assigned patients in blocks of 20 in four strata (cardiac or non-cardiac surgery; positive or negative recent fall history) to electroencephalography-guided or usual anaesthetic care. Participants and investigators were blinded to group assignment. Delirium was assessed for 5 postoperative days, using structured chart review and daily Confusion Assessment Method. We analysed by intention-to-treat and assessed adverse events. Findings: Between Jan 16, 2015 and May 7, 2018, 39144 patients were screened, and 1232 patients were randomly assigned, with 614 in the electroencephalography-guided and 618 in the usual care group. Compared with usual care, the guided group had a 14% median decrease in volatile anaesthetic administration, and a 46% reduction in the median [interquartile range] intraoperative time with electroencephalogram suppression (7 [1 to 23] vs 13 [2 to 58] minutes, p