Outcome of open total arch replacement in the modern era

Abstract

The main findings from this meta-analysis indicate that total aortic arch replacement can be performed with satisfactory mortality and morbidity. The pooled rates of mortality and permanent neurologic deficit among elective cases were surprisingly low, and these data have an even greater prominence when they are compared with outcomes of hybrid arch series. Under urgent/emergency surgery, early mortality and neurologic complications showed an about threefold higher rate. Moderate hypothermic circulatory arrest and early rewarming seem to provide proper renal protection, with an intermediate risk of prolonged intubation.

Deep chronic microvascular white matter ischemic change as an independent predictor of acute brain infarction after thoracic aortic replacement

“…Modern advancements in open surgical techniques have contributed to better outcomes and lower complication rates for thoracic aortic replacement surgery . The overall decreases in mortality rates have also coincided with the implementation of HCA brain protection techniques, which are now an essential part of thoracic aortic replacement surgery .…”

“…However, our reported rate is in line with more current literature. Settepani et al in a review of 21 studies of patients who underwent open thoracic aortic arch surgery, found that the pooled postoperative permanent and transient neurologic deficit rate were 3.4% and 5.2%, and in elective patients 2.9% and 2.2%, respectively. Similar low rates have been reported in other studies.…”

“…12 The overall decreases in mortality rates have also coincided with the implementation of HCA brain protection techniques, which are now an essential part of thoracic aortic replacement surgery. 12 Yet, while several studies have shown improved outcomes for patients who undergo thoracic aortic replacement with HCA, 13,14 the occurrence of postsurgical acute brain infarctions still has profound consequences. 7 Currently, in our practice we utilize optimal neuroprotective strategies, including retrograde, antegrade, and direct arch cerebral perfusion in elective patients which has decreased mortality and the rate of acute strokes.…”

Hybrid and total endovascular repair of the aortic arch

“…Replacement of the aortic arch with a Dacron® prosthesis may be future‐proofed for subsequent disease progression or the need for staged treatment by leaving an elephant trunk (everted length of tube graft) or frozen elephant trunk (attached stent‐graft deployed antegradely) in the descending thoracic aorta to provide a suitable proximal landing zone for subsequent thoracic endovascular repair (TEVAR). A recent meta‐analysis of 21 studies, comprising some 2880 patients undergoing open arch repair, gave pooled elective operative mortality and permanent neurological deficit rates of 2·9 and 2·2 per cent respectively. There was a threefold increase in these rates in patients requiring urgent or emergency surgery.…”

Case series of aortic arch disease treated with branched stent-grafts

“…Open repair is the reference standard, but requires cardiopulmonary bypass and hypothermic circulatory arrest and is associated with mortality and an incidence of cardiac and cerebrovascular events. The contemporary results of these procedures have been detailed in a recent meta‐analysis, which reported rates of operative mortality of 5·3 per cent, permanent stroke 3·4 per cent, permanent spinal cord injury 0·6 per cent and renal failure 4·1 per cent. The literature also demonstrates that the mortality and morbidity associated with these procedures increases markedly when significant co‐morbid factors are present, and these risks can preclude surgery.…”