Total arch replacement using antegrade cerebral perfusion

ObjectiveThe technical details of total arch replacement using antegrade cerebral perfusion are presented.MethodsFrom January 2002 to May 2012, 423 consecutive patients (mean age, 69.2 ± 13.1 years) underwent total arch replacement using antegrade selective cerebral perfusion through a median sternotomy. Acute aortic dissection was present in 81 patients (19.1%; 75 type A, 6 type B), and a shaggy aorta was present in 37 patients (8.7%). Emergency/urgent surgery was required in 135 patients (31.9%). Our current approach included meticulous selection of the arterial cannulation site and type of arterial cannula, antegrade selective cerebral perfusion, maintenance of the minimal tympanic temperature between 20°C and 23°C, early rewarming immediately after distal anastomosis, and maintenance of the fluid balance at less than 1000 mL during cardiopulmonary bypass. A woven Dacron 4-branch graft was used in all patients.ResultsThe overall hospital mortality was 4.5% (19/423): 9.6% (13/135) in urgent/emergency surgery cases and 2.1% (6/288) in elective cases. Permanent neurologic deficits occurred in 3.3% patients (14/423). Prolonged ventilation was necessary in 57 patients (13.4%). A multivariate analysis demonstrated the risk factors for hospital mortality to be age (octogenarian; odds ratio, 4.45; P = .02), brain malperfusion (odds ratio, 22.5; P = .002), and cardiopulmonary bypass time (odds ratio, 1.06; P = .04). The follow-up was completed in 97.2% of patients (mean, 29 ± 27; 1-126) and included 2.3 patients per year. Survival at 5 and 10 years after surgery was 79.6% ± 3.3% and 71.2% ± 5.0%, respectively. In the acute A dissection group, the 10-year survival was 96.6% ± 2.4%. In the elective nondissection group, the 5- and 10-year survivals were 80.3% ± 4.2% and 76.1% ± 5.7%, respectively.ConclusionsOur current approach for total aortic arch replacement is associated with low hospital mortality and morbidity, thus leading to a favorable long-term outcome.