Mild Systemic Hypothermic Circulatory Arrest Using a Frozen Elephant Trunk Graft with Endo-Balloon Occlusion for Total Arch Replacement

Abstract

Background: Stroke and paraplegia are serious complications of total aortic arch replacement (TAR). Hypothermic circulatory arrest and cerebral perfusion reduce the risk of neurologic complications, but longer circulatory arrest time remains a risk factor for such complications. We utilized a frozen elephant trunk (FET) with endo-balloon occlusion under mild systemic hypothermia, which allowed us to shorten circulatory arrest time. Methods: Between April 2007 and May 2020, 72 patients underwent elective TAR using antegrade cerebral perfusion (ACP). They were divided into 2 groups. 64 patients received conventional TAR with moderate systemic hypothermic (bladder temperature, 25–28°C) circulatory arrest (group C). We used a FET with endo-balloon occlusion and retrograde perfusion through the femoral artery for the newest 8 patients who had mild hypothermic (bladder temperature of 30°C) circulatory arrest (group B). Results: The mean operation time (257.5 ± 42.1 versus 327.8 ± 84.9 min, P = .023), CPB time (144.4 ± 28.1 versus 178.2 ± 26.4 min, P = .003), cardiac arrest time (75.5 ± 21.2 versus 95.7 ± 56.4 min, P < .001), SCP time (100.8 ± 25.5 versus 124 ± 23.2 min, P < .001), lower body circulation arrest time (17.2 ± 4.2 versus 62.5 ± 19.3 min, P < .001) were significantly shorter in the endo-balloon occlusion group. There were no perioperative neurological and renal complications or mortality in FET group. The new technique enabled a decrease in mechanical ventilation time (8.6 ± 1.4 versus 13.9 ± 5.7 min, P = .015) and hospital length of stay (9.7 ± 1.8 versus 18.3 ± 4.6 min, P = .005). Conclusion: FET using an endo-balloon occlusion with mild hypothermia is a safe and an effective approach in TAR.

Clinical outcomes of mild versus moderate hypothermic circulatory arrest with antegrade cerebral perfusion in adult aortic arch surgery: A systematic review and meta-analysis

“…Then a preliminary screening was made by reading titles and abstracts, and next the full texts were downloaded and assessed for eligibility. Eleven studies [21][22][23][24][25][26][27][28][29][30][31] were finally included. Search flow diagram of the present meta-analysis was depicted in Figure 1.…”

“…Modified technique developed by Li et al shortened the HCA time from 16-28 min to 1-3 min. 28 HCA combined with lower body perfusion [27][28][29] reduces ischemic time of visceral organs and spinal cord. And nowadays novel branch-first technique can avoid HCA.…”

“…The HCA temperatures adopted in different studies were based on clinical experience, [21][22][23][24]30 new surgical techniques shorting HCA time and raising temperature level meanwhile, 27,29 surgeon decision, 25 and random allocation in the RCT. 26 Temperature measuring sites including bladder/rectum, 21,23,24,26,27,30,31 esophagus, 21 nasopharynx, 26,29,30 core, 25 and blood. 22 Bladder/ rectum temperature was preferred for grouping according to temperature classification 14 if nasopharyngeal temperature was also reported.…”

Normothermic frozen elephant trunk: our experience and literature review

“…At an average systemic temperature of 31 ℃, after exploration of the aortic arch and preparation of the distal aortic stump, a membranous stent graft (MicroPort, Shanghai, China) was anchored to the inner wall of the descending thoracic aorta and occluded with a 16 French urethral catheter. Systemic perfusion through the femoral artery was resumed thereafter for a mean lower body Mild systemic circulatory arrest for arch and FET repair using and endoballoon occlusion was described by Goto et al (45) in 8 patients. Their method provided femoral and left subclavian artery cannulation for arterial return, selective antegrade cerebral perfusion and systemic cooling at 30 ℃ of bladder temperature.…”

“…Compared to the techniques reported and discussed in the previous paragraph using an antegradely delivered endoballoon (43)(44)(45)(46), our approach:…”