Clinical Results of Ascending Aorta and Aortic Arch Replacement under Moderate Hypothermia with Right Brachial and Femoral Artery Perfusion

Abstract

BackgroundSelective antegrade perfusion via axillary artery cannulation along with circulatory arrest under deep hypothermia has became a recent trend for performing surgery on the ascending aorta and aortic arch and when direct aortic cannulation is not feasible. The authors of this study tried using moderate hypothermia with right brachial and femoral artery perfusion to complement the pitfalls of single axillary artery cannulation and deep hypothermia.Materials and MethodsA retrospective analysis was performed on 36 patients who received ascending aorta or aortic arch replacement between July 2005 and May 2010. The adverse outcomes included operative mortality, permanent neurologic dysfunction and temporary neurologic dysfunction.ResultsOf these 36 patients, 32 (88%) were treated as emergencies. The mean age of the patients was 61.9 years (ranging from 29 to 79 years) and there were 19 males and 17 females. The principal diagnoses for the operation were acute type A aortic dissection (31, 86%) and aneurysmal disease without aortic dissection (5, 14%). The performed operations were ascending aorta replacement (9, 25%), ascending aorta and hemiarch replacement (13, 36%), ascending aorta and total arch replacement (13, 36%) and total arch replacement only (1, 3%). The mean cardiopulmonary bypass time was 209.4±85.1 minutes, and the circulatory arrest with selective antegrade perfusion time was 36.1±24.2 minutes. The lowest core temperature was 24±2.1℃. There were five deaths within 30 post-op days (mortality: 13.8%). Two patients (5.5%) had minor neurologic dysfunction and six patients, including three patients who had preoperative cerebral infarction or unconsciousness, had major neurologic dysfunction (16.6%).ConclusionWhen direct aortic cannulation is not feasible for ascending aorta and aortic arch replacement, the right brachial and femoral artery can be used as arterial perfusion routes with the patient under moderate hypothermia. This technique resulted in acceptable outcomes.

Innominate artery cannulation for arterial perfusion during aortic arch surgery

“…The combined use of antegrade and retrograde femoral artery perfusion during aortic arch surgery may improve visceral perfusion and minimize retrograde embolization. 12,21,22 We experienced no complications related to IA perfusion, such as pseudoaneurysm or dissection. The relatively long hospital stay was most likely due to the older age of the patients and need for TEVAR for the descending aorta after aortic arch surgery during the same hospitalization (14 patients, 8.9%).…”

“…So, to relieve turbulence of the aortic arch, we use femoral artery perfusion concomitantly and decrease IA perfusion flow. The combined use of antegrade and retrograde femoral artery perfusion during aortic arch surgery may improve visceral perfusion and minimize retrograde embolization …”

Selective cerebral perfusion with 4-branch graft total aortic arch replacement: Outcomes in 12 patients

“…Because the duration of hypothermic circulatory arrest and increasing age are important predictors of temporary neurologic dysfunction and of fine-motor and memory deficits after aortic arch surgery, reducing the duration of circulatory arrest should reduce the prevalence of these complications [ 20 ]. Lastly, while some authorities find it controversial to perform SABP in patients with acute type A dissection due to a higher risk of neurological complications, a number of very recent studies that have shown SABP for acute type A aortic dissection provides acceptable results [ 21 - 24 ].…”