Arterial Access Through the Right Subclavian Artery in Surgery of the Aortic Arch Improves Neurologic Outcome and Mid-Term Quality of Life

Immer, Franz F.; Moser, Barbara; Krähenbühl, Eva; Englberger, Lars; Stalder, Mario; Eckstein, Friedrich S.; Carrel, Thierry

doi:10.1016/j.athoracsur.2007.11.027

Cited by 54 publications

(38 citation statements)

References 18 publications

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“…The guidelines suggest axillary artery access as the first choice for surgery of the aortic arch and aortic dissection [1]. Immer et al [12] showed a significantly better neurological outcome for patients undergoing cerebral perfusion through the right axillary artery compared with selective antegrade perfusion. Over the last few years, the Leipzig group have used routinely axillary access for arch surgery and they have not found any effect of the cannulation site on neurological or other perioperative outcome [10].…”

Section: Resultsmentioning

confidence: 99%

Single-centre experience in surgery of acute aortic type A dissection and true aortic arch aneurysm

et al. 2016

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A b s t r a c tBackground: Surgery of the aortic arch is challenging. Aim:To assess the results of aortic arch surgery. Methods:Analysis of 172 patients operated on arch dissection (emergency group: 97 patients) or aneurysm (elective group: 75 patients) between 2007 and 2014. Arch surgery was defined as a procedure requiring circumferential anastomosis at the level of the aortic arch or the descending aorta with the use of techniques of brain protection (deep hypothermic circulatory arrest [DHCA] or selective antegrade cerebral perfusion [SACP]) and/or debranching of at least one supra-aortic vessel.Results: Men predominated in both groups (> 70%). Men were younger in the emergency group (55 vs. 66 years; p < 0.008). The operative risk was higher in the emergency group (19.2% vs. 12.5%; p < 0.001). Forty-nine per cent of the patients from the emergency group and 5% from the elective group were operated with antiplatelet therapy (p < 0.001). Extended hemiarch procedure was performed in 79% (n = 77) in the emergency and 76% (n = 57) in the elective group. Total arch replacement was performed in 19 (21%) patients from the emergency and 18 (24%) patients from the elective group. In these patients debranching was performed in 68% of the emergency patients group and in 67% of the elective group. Elephant trunk procedure (classic/frozen) was performed in 53% (n = 10) from the emergency and in 78% (n = 14) of patients from the elective group. Aortic valve sparing surgery was performed in 20% of patients from the emergency and 9% from the elective group (p = 0.063). DHCA was performed in 58% (n = 43) of patients from the elective group and 39% (n = 37) from the emergency group. SACP was performed in 61% (n = 58) of patients from the emergency and 42% (n = 31) from the elective group. Thirty-day mortality in the emergency group reached 33% (n = 32), and in the elective group 15% (n = 11; p = 0.007). In multivariate analysis, predictors of death in the emergency group were: Logistic EuroSCORE above 19.5%, extracorporeal circulation time above 228 min, and postoperative acute renal failure (ARF); and in the elective group: DHCA time above 26 min, rethoracotomy due to bleeding, and ARF. Follow-up was completed in 100% of patients in terms of vital status. The mean follow-up time of the patients from the emergency group was 24.3 ± 27.10 (min 0, max 92) months, and from the elective group 30.3 ± 24.5 (min 0, max 99) months. During the follow-up period all-cause mortality in the emergency group was 43% (n = 42/97), and in the elective group it was 36% (n = 27/75). Conclusions:Early mortality in the emergency group was higher, while long-term mortality did not differ among the groups. Postoperative ARF is a critical predictor of mortality in both groups.

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Section: Resultsmentioning

confidence: 99%

Single-centre experience in surgery of acute aortic type A dissection and true aortic arch aneurysm

et al. 2016

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“…Perfusion pressures should usually be 40 to 70 mm Hg, and flow rates should be 10 mL ⅐ kg Ϫ1 ⅐ min Ϫ1 or approximately 1000 mL/min, regardless of the ACP technique used. [7][8][9][15][16][17] In our survey, most surgeons aimed for or even exceeded these values. We detected a substantially reduced risk for PNDmc at perfusion pressures that exceeded 60 mm Hg and a mild risk reduction at flow rates that exceeded 600 mL/min.…”

Section: Cerebral Perfusionmentioning

confidence: 98%

“…Cerebral malperfusion in uACP has been rare in clinical experience, and several groups have reported impressive results. 7,8,16 Observation of back flow from the left carotid and subclavian arteries and monitoring of transcranial oxygen saturation and left tympanic temperature may further reduce this risk. 21 The threats of plexus injury and arterial stenosis are low.…”

Section: Differences In Cerebral Protection Strategiesmentioning

confidence: 99%

Cerebral Protection During Surgery for Acute Aortic Dissection Type A

et al. 2011

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on behalf of the GERAADA Investigators Background-Cerebral protection during surgery for acute aortic dissection type A relies on hypothermic circulatory arrest, either alone or in conjunction with cerebral perfusion. Methods and Results-The perioperative and intraoperative conditions of 1558 patients submitted from 44 cardiac surgery centers in German-speaking countries were analyzed. Among patients with acute aortic dissection type A, 355 (22.8%) underwent surgery with hypothermic circulatory arrest alone. In 1115 patients (71.6%), cerebral perfusion was used: Unilateral antegrade cerebral perfusion (ACP) in 628 (40.3%), bilateral ACP in 453 (29.1%), and retrograde perfusion in 34 patients (2.2%). For 88 patients with acute aortic dissection type A (5.6%), no circulatory arrest and arch intervention were reported (cardiopulmonary bypass-only group). End points of the study were 30-day mortality (15.9% overall) and mortality-corrected permanent neurological dysfunction (10.5% overall). The respective values for the cardiopulmonary bypass-only group were 11.4% and 9.1%. Hypothermic circulatory arrest alone resulted in a 30-day mortality rate of 19.4% and a mortality-corrected permanent neurological dysfunction rate of 11.5%, whereas the rates were 13.9% and 10.0%, respectively, for unilateral ACP and 15.9% and 11.0%, respectively, for bilateral ACP. In contrast with the ACP groups, there was a profound increase in mortality when systemic circulatory arrest times exceeded 30 minutes in the hypothermic circulatory arrest group (PϽ0.001). Mortality-corrected permanent neurological dysfunction correlated significantly with perfusion pressure in the ACP groups. Conclusions-This

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“…While Lee et al reported that there was no significant difference in the incidence of cerebral complications between right axillary arterial perfusion and femoral arterial perfusion, 84) there are a number of reports on the superiority of the former. 43,85,86) The right axillary artery is mostly used 87,88) and also utilized for antegrade cerebral perfusion during circulatory arrest. Kano et al have used left axillary arterial perfusion with fairly good results, 89) although a small sized artery may cause an inadequate perfusion rate in some cases.…”

Section: Perfusion Routementioning

confidence: 99%

Acute Type A Aortic Dissection: for Further Improvement of Outcomes

Orihashi¹

2012

Annals of Vascular Diseases

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Despite improved outcomes of acute type A aortic dissection (AAAD), many patients die at the moment of onset, and hospital mortality is still high. This article reviews the latest literature to seek the best possible way to optimize outcomes. Delayed diagnosis is caused by variation in or absence of typical symptoms, especially in patients with neurological symptoms. Misdiagnosis as acute myocardial infarction is another problem. Improved awareness by physicians is needed. On arrival, quick admission to the OR is desirable, followed by assessment with transesophageal echocardiography, and malperfusion already exists or newly develops in the OR; thus, timely diagnosis without delay with multimodality assessment is important. Although endovascular therapy is promising, careful introduction is mandatory so as not to cause complications. While various routes are used for the systemic perfusion, not a single route is perfect, and careful monitoring is essential. Surgical treatment on octogenarians is increasingly performed and produces better outcomes than conservative therapy. Complications are not rare, and consent from the family is essential. Prevention of AAAD is another important issue because more patients die at its onset than in the following treatment. In addition to hereditary diseases, including bicuspid aortic valve disease, the management of blood pressure is important.Keywords: aortic dissection, malperfusion, complication, echocardiography A cute type A aortic dissection (AAAD) not only causes sudden death at the time of onset but leads to various life-threatening complications. In spite of improved diagnostic imaging and surgical strategies, in-hospital mortality is still high, and patients who have survived often suffer from sequelae that make subsequent quality of life poor. This article is aimed to review the latest literature and ideas to seek the best possible way to minimize undesirable results.Various complications of AAAD caused by separation of the aortic wall to outer and inner layers are summarized as three categories: 1) aortic rupture due to disruption of the outer layer; 2) malperfusion caused by the inner layer, that is, the intimal flap; and 3) aortic regurgitation by a deformed aortic valve, leading to acute heart failure. Approximately 20% of patients instantaneously die due to aortic rupture, 1) and 1 to 2% of the remaining patients die every hour unless appropriately treated. 2) Although surgical outcomes are gradually improving, in-hospital mortality of surgical patients (repair on the aortic root to the arch) in 2009 was as high as around 10%, according to the Japanese database. 3) For the further improvement of outcomes, problems should be solved in each of preonset, pre-hospital, and in-hospital stages. In this review, the latter two stages are discussed first, since most of the literature focuses on these stages. After that, the issue of pre-onset stage, i.e., prevention is discussed. DelayeD DiagnosisIn consideration of the natural history of AAAD, the "chain of onset-to-sur...

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Arterial Access Through the Right Subclavian Artery in Surgery of the Aortic Arch Improves Neurologic Outcome and Mid-Term Quality of Life

Cited by 54 publications

References 18 publications

Single-centre experience in surgery of acute aortic type A dissection and true aortic arch aneurysm

Single-centre experience in surgery of acute aortic type A dissection and true aortic arch aneurysm

Cerebral Protection During Surgery for Acute Aortic Dissection Type A

Acute Type A Aortic Dissection: for Further Improvement of Outcomes

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