Long-term outcomes of hemiarch replacement with hypothermic circulatory arrest and retrograde cerebral perfusion

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Background: With evolutions in technique, recent data encourage the use of cerebral perfusion during aortic arch repair. However, a randomized data have demonstrated higher rates of neurologic injury according to MRI lesions using antegrade cerebral perfusion during hemiarch reconstruction.Methods: This was a retrospective review of two institutional aortic center databases to identify adult patients who underwent aortic hemiarch reconstruction for elective aortic aneurysm or acute type A aortic dissection. Patients were stratified according to cerebral protection method: (1) deep hypothermic circulatory arrest (DHCA) group versus (2) DHCA/retrograde cerebral perfusion (RCP) group.Results: A total of 320 patients and 245 patients underwent hemiarch reconstruction for aortic aneurysm electively and aortic dissection, respectively. In aneurysmal pathology, the DHCA group included 133 patients and the DHCA/RCP group included 187 patients. Operative mortality was 0.8% in the DHCA group and 2.7% in the DHCA/RCP group (p = 0.41). Kaplan-Meier survival estimates revealed comparable 2-year survival (p = 0.14). In dissection, 43 patients and 202 patients were included in the DHCA group and the DHCA/RCP group, respectively.Operative mortality was equivalent between the two groups (11.6% in the DHCA group and 9.4% in the DHCA/RCP group, p = 0.58). Long-term survival was similar at 2 years between the groups (p = 0.06). Multivariable analysis showed cerebral perfusion strategy was not associated with the composite outcome of operative mortality and stroke.

Section: Discussionmentioning

confidence: 89%

Section: Discussionmentioning

confidence: 93%

Section: Discussionmentioning

confidence: 99%

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Cerebral protection using deep hypothermic circulatory arrest versus retrograde cerebral perfusion for aortic hemiarch reconstruction

Arnaoutakis

Ogami

Bobba

et al. 2022

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“…This institutional algorithm of preferentially performing hemiarch replacement, except for the four situations when TAR is performed, has resulted in acceptable neurologic outcomes and operative mortality 18,19 . When there is dissection into the carotid body or carotid artery thrombosis, a concomitant carotid replacement is performed via an oblique cervical incision.…”

Section: Methodsmentioning

confidence: 99%

The long‐term impact of acute renal failure after aortic arch replacement for acute type A aortic dissection

Brown

Serna‐Gallegos

Navid

et al. 2022

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Objective: To determine the long-term impact of developing acute renal failure (ARF) on survival after open aortic arch reconstruction for acute type A aortic dissection (ATAAD). Methods:This was an observational study of consecutive aortic surgeries from 2007 to 2021. Patients with ATAAD were identified via a prospectively maintained institutional database and were stratified by the presence or absence of postoperative ARF (by RIFLE criteria). Kaplan-Meier survival estimation and multivariable Cox regression analysis were performed.Results: A total of 601 patients undergoing open surgery for ATAAD were identified, of which 516 (85.9%) did not develop postoperative ARF, while 85 (14.1%) developed ARF, with a median follow-up time of 4.6 years (1.6, 7.9). Baseline characteristics were similar across each group, except for higher rates of branch vessel malperfusion and lower preoperative ejection fraction in the ARF group.Patients with ARF underwent more total arch replacement and elephant trunk procedures, with longer cardiopulmonary bypass and circulatory arrest times than patients without ARF. ARF was associated with worse short-term outcomes, including increased in-hospital mortality, prolonged mechanical ventilation, higher rates of sepsis, more blood transfusions, and longer length of hospital stay.Unadjusted Kaplan-Meier survival estimates were significantly lower in the ARF group, compared to the group without ARF (p < .001, log-rank test). After multivariable adjustment, the development of postoperative ARF was significantly associated with an increased hazard of death over the study's follow-up time-period (hazard ratio: 2.74, 95% confidence interval: 1.95, 3.86, p < .001).Conclusions: ARF is a highly morbid postoperative event that may adversely impact long-term survival after aortic surgery.

“…Hypothermic circulatory arrest (HCA) is used for proximal and total aortic arch correction in patients with proximal aortic arch aneurysm and acute or chronic type A aortic dissection 1–4 . Different cerebral perfusion techniques for thoracic aorta pathologies have been proposed to reduce morbidity and mortality rate.…”

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confidence: 99%

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

Samanidis

Kanakis

Kolovou

2022

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.