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Ann Thorac Surg 2000;70:3-8
© 2000 The Society of Thoracic Surgeons

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Original articles: Cardiovascular

Total arch replacement using aortic arch branched grafts with the aid of antegrade selective cerebral perfusion

^a First Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
^b Second Department of Surgery, Sapporo Medical University, Sapporo, Japan

Address reprint request to Dr Kazui, First Department of Surgery, Hamamatsu University School of Medicine, 3600 Handa-cho, Hamamatsu, 431–3192, Japan
e-mail: surg1ss{at}hama-med.ac.jp

Presented at the Thirty-sixth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 31–Feb 2, 2000.

	Abstract

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Background. We report our clinical experience with total arch replacement using aortic arch branched graft in an attempt to determine the independent predictors of both in-hospital mortality and neurologic outcome.

Methods. We studied 220 consecutive patients who underwent total arch replacement using aortic arch branched graft between May 1990 and June 1999. All operations were performed with the aid of hypothermic extracorporeal circulation, antegrade selective cerebral perfusion, and open distal anastomosis.

Results. The overall in-hospital mortality rate was 12.7%. Multivariable analysis showed independent determinants of in-hospital mortality to be chronic renal failure, long pump time, participation in early series, and shock. Postoperative permanent neurologic dysfunction was 3.3%. On multivariable analysis, old cerebral infarct and pump time were independent determinants of permanent neurologic dysfunction. The selective cerebral perfusion time had no significant influence on in-hospital mortality or neurologic outcome. The 5-year survival rate including in-hospital deaths was 79% ± 6%.

Conclusions. Selective cerebral perfusion allows increased ease of performance of total arch replacement, a complex and time-consuming procedure, and helps reduce periprocedural mortality and morbidity in patients with aortic arch aneurysm and those with acute aortic dissection.

	Introduction

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It is well known that both the method used for cerebral protection during aortic arch repair and the operative technique for aortic arch reconstruction significantly influence operative outcome in patients undergoing repair of aortic arch aneurysms.

Among the widely used methods for prevention of cerebral ischemia during the operative treatment of aortic arch aneurysm are profound hypothermic circulatory arrest (HCA) [1–3], retrograde cerebral perfusion (RCP) [4–7], and antegrade selective cerebral perfusion (SCP) [8–11]. Approaches to total arch replacement include the island technique, or en bloc technique, in which the arch vessels are reconstructed in island fashion, and the separated graft technique, which uses an aortic arch branched graft.

The aim of the present study is to determine the independent predictors of neurologic outcome and in-hospital mortality and to report long-term results in patients who received total arch replacement employing the separated graft technique using hypothermic cardiopulmonary bypass (CPB) and selective cerebral perfusion (SCP).

	Material and methods

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Patient profiles
Two hundred and twenty consecutive patients with aortic arch disease underwent total arch replacement using the separated graft technique with the aid of CPB and SCP; all procedures were performed by the senior author (T.K.) between May 1990 and June 1999. Excluded from the study were 32 patients who underwent arch repair during the same period by other approaches (en bloc technique or hemiarch replacement) or using other methods of cerebral protection (HCA or RCA). The study patients ranged in age from 18 to 86 years (mean, 62 ± 13 years); 148 (67%) were men and 72 (33%) women. Seventy patients (32%) were treated for acute aortic dissection, 50 (23%) for chronic aortic dissection, and 100 (45%) for degenerative aneurysm. Seventy-four patients (34%) underwent emergent operations within 24 hours of admission; of those, 68 sustained acute aortic dissection and 6 rupture of aneurysms. Preoperative complications included shock in 22 patients (10%), hemodynamic compromise necessitating endotracheal intubation in 15 (7%), chronic obstructive pulmonary disease (COPD) in 19 (9%), chronic renal failure in 22 (10%) including 4 requiring hemodialysis, annuloaortic ectasia in 34 (15%), old cerebral infarct in 16 (7%), and coronary artery disease in 27 (12%). Acute aortic dissection-related complications included acute aortic regurgitation in 25 patients (36%), myocardial ischemia in 7 (10%), cerebral ischemia in 8 (11%), cardiac tamponade in 33 (47%), renal or mesenteric ischemia in 10 (14%), leg ischemia in 11 (16%), and paraplegia in 2 (3%). Forty-two patients (19%) had undergone a total of 59 previous cardiovascular operations, including 21 (10%) procedures involving the ascending aorta or the arch or both, 7 (3%) involving the descending aorta, and 15 (7%) the aortoiliac artery. Additionally, 2 patients (1%) underwent axillofemoral bypass, 3 (1%) aortic valve replacement, and 5 (2%) composite graft replacement. Preoperative aortography or digital subtraction angiography was performed in all patients undergoing elective procedures; other imaging procedures (four-vessel angiography, cerebral computed tomography, or magnetic resonance imaging) were also performed when necessary.

Operative techniques
The heart, ascending aorta, aortic arch, arch vessels, and proximal descending aorta were exposed through median sternotomy in 216 patients (98%) and through median sternotomy plus left-lateral thoracotomy in 4 (2%). The details of hypothermic CPB and antegrade SCP have been described in full previously [9, 12]. Briefly, after the patient was placed on extracorporeal circulation and cooled down to a rectal temperature of 22°C, systemic circulation was arrested and the aorta was opened. Both the innominate and the left common carotid arteries were completely transected either at their origins or at their intact portions, where no atherosclerotic plaque or dissection was present; the arteries were then cannulated through the arteriectomy sites. Cannula sizes used were 18F for innominate artery perfusion and 14F for left common carotid artery perfusion. During cannulation of the arch vessels, perfusion was continued so that air might be removed from the cannula while the arch vessels remained cross-clamped. After cannulation, the balloon attached to the tip of the cannula was inflated and secured with rubber tape to prevent displacement of the cannula.

Selective cerebral perfusion was started at the rate of 10 mL · kg^-1 · min^-1 using a single roller pump, separate from the systemic circulation. The left subclavian artery (LSA) was clamped during SCP. During distal aortic anastomosis, systemic perfusion to the lower half of the body was arrested. The operative approach for aortic arch reconstruction used in all patients was the separated graft technique. Vascular prostheses used in procedures performed before 1992 were of low porosity woven Dacron preoperatively treated with the albumin-autoclave method; after 1992 we used commercially available grafts sealed with collagen or gelatin (Hemashield, Meadox Medical, Oakland, NJ, or Gelweave, Sulzer Vascutek, Renfrewshire, Scotland, UK). Grafts used in the early period were handmade, constructed in the operating room; after 1997 we used ready-made commercially available grafts (Hemashield Branched Graft, Meadox Medical, Oakland, NJ).

An aortic arch graft with three branches was used in the first 51 patients (23%), who were operated on before April 1993. The distal side of this arch graft was anastomosed to the proximal descending aorta. The graft was cross-clamped proximally, and extracorporeal circulation was started from the LSA branch for rewarming. The three branches of the graft were anastomosed in succession to the innominate artery, the left common carotid artery, and the LSA. An aortic arch graft with four branches was used in the 169 patients (77%) operated on after April 1993. The distal side of this arch graft was anastomosed to the proximal descending aorta, and the third branch was anastomosed to the LSA. The graft was cross-clamped proximally, and antegrade extracorporeal circulation was started from the fourth branch, together with rewarming. The proximal graft was ananastomosed to the ascending aorta and coronary circulation was started. The first and second branches of the graft were then anastomosed to the innominate and left common carotid arteries, respectively. Once extracorporeal circulation was terminated, the fourth branch, used for antegrade perfusion, was resected. The extent of aortic replacement was as follows: replacement of the ascending aorta and total arch was performed in 97 patients (44%), total arch replacement in 3 (1%), replacement of the total arch and proximal descending aorta (defined as replacement of the descending aorta with distal anastomosis located from 5 to10 cm from the origin of the LSA) in 7 (3%), and extended aortic replacement (defined as an ascending aorta, total arch, and proximal descending aorta replacement) in 113 (51%). The elephant trunk technique was performed in 28 patients (13%). Concomitant procedures included composite graft replacement with coronary reimplantation in 33 patients (15%) including repeat operations in 5 (2%), coronary artery bypass grafting in 24 (11%), aortic valve replacement in 7 (3%), aortic valve resuspension for acute dissection in 16 (7%), mitral valve replacement or repair in 3 (1%), Doty’s extended aortoplasty in 1 (0.5%), abdominal aortic replacement in 1 (0.5%), and left vertebral artery reconstruction in 4 (2%).

Follow-up
Study patients were followed until July 1999 at the outpatient clinic or by telephone or letter contact. Follow-up was 99% complete. The mean follow-up period was 39.0 ± 29.9 months with a maximum of 100 months.

Statistical methods
The continuous data in this study are expressed as the mean ± standard deviation (SD). Independent risk factors for in-hospital mortality and neurologic outcome were derived from 32 preoperative and postoperative variables (see Appendix), examined by multivariable analysis using a forward stepwise logistic regression model. Survival and repeat operation rates were estimated by the Kaplan-Meier method, with variability expressed as ± 95% confidence interval; differences in survival were determined by log-rank analysis. All computations were performed using SPSS 6.1 for UNIX (SPSS, Chicago, IL) and StatView 5.0 (SAS Institute, Cary, NC) statistical software packages.

	Results

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In-hospital mortality
Five patients died either in the operation room or in the intensive care unit within 24 hours of the operation; the remainder survived the operation. Overall, 28 of 220 patients died during hospitalization, for an in-hospital mortality rate of 12.7% (95% CI, 8.3% to about 17.2%). Of the 28, 14 underwent an operation for acute aortic dissection, 7 for true aneurysm; and 1 for aneurysm rupture. Additionally, 6 of those patients underwent a repeat operation of the ascending aorta or aortic arch, or both; Causes of in-hospital death were multiple organ failure in 11 patients, bleeding in 3, sepsis in 3, low cardiac output syndrome in 2, acute myocardial infarction in 2, acute respiratory distress syndrome in 2, late cardiac tamponade in 2, massive gastrointestinal bleeding in 1, aspiration pneumonia in 1, and rupture of the descending aorta in 1. Table 1 shows the following independent determinants of in-hospital mortality revealed by multivariable analysis: chronic renal failure, pump time > 300 minutes, early series (operation performed before April 1993), and shock. The in-hospital mortality rates of patients without chronic renal failure, with pump time of less than 300 minutes, belonging to the late series, and with no shock were 9.6%, 9.2%, 7.1%, and 10.6%, respectively.

Extracorporeal circulation
Data describing extracorporeal circulation for all patients are as follows: the mean total pump time was 197.4 ± 65.5 minutes; the mean aortic cross clamping time, 122.1 ± 39.4 minutes; the mean SCP time, 87.2 ± 24.2 minutes; and the mean circulatory arrest time, 44.5 ± 18.3 minutes. Table 3 shows the distribution of SCP time and the correlation between SCP time and in-hospital mortality or neurologic outcome rate. There was no significant correlation between SCP time and in-hospital mortality or neurologic outcome rate.

View larger version (13K): [in this window] [in a new window]   Fig 1. Actuarial survival curve estimated by the Kaplan-Meiyer method in patients who received total arch replacement by the separated graft technique. Bar indicates 95% confidence interval.

	Comment

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Since 1957, when DeBakey and colleagues [13] first applied SCP clinically as a way of protecting the brain during aortic arch repair, SPC has been used at many institutions. However, criteria for perfusion site, volume, pressure, and temperature have not been established and thus the details of the procedure have varied among institutions. For this reason, results of cerebral protection by SCP have not been consistent.

Our experimental study suggested that the safe range of flow rates for cerebral perfusion during moderate hypothermia is greater than 50% of the physiologic level with a perfusion pressure of no less than about 30 mm Hg [14]. In the clinical setting, a perfusion volume of 10 mL · kg^-1 · min^-1 is considered to be 50% or more of the physiologic flow rate of cerebral circulation. At our institution, complicated total arch replacement usually requires a period of brain protection of approximately 60 to 90 minutes. We therefore performed an experimental study to compare cerebral protection efficacy of HCA, RCA, and SCP and found that SCP was the safest method for arch reconstruction that requires a cerebral protection period of 90 minutes [15]. We found SCP to be physiologically superior to HCA and RCP because it supplies sufficient oxygenated blood to the brain in an antegrade direction and therefore can be used to protect the brain for an unlimited time.

Though SCP is considered to be a cumbersome procedure that clutters the operative field, we have simplified the technique somewhat, perfusing two arteries with one pump and monitoring only the right radial artery. We use a flexible perfusion cannula and place it towards the patient’s head side after cannulation so that it does not obscure the operative field. A suggested drawback of SCP is the risk of cerebral infarction due to dislodgment of debris by insertion of the perfusion cannula. However, this complication can be avoided by direct insertion of the cannula in the arteriectomy site. Another disadvantage of SCP is the risk of cannulating arch vessels that are involved in the dissection. However, in acute cases the true lumen can be distinguished from the false lumen and direct cannulation from the arteriectomy site to the true lumen is not difficult. No complication related to cannulation has been observed in our series.

Both hemiarch replacement and total arch replacement have been used as techniques for aortic arch repair. An advantage of total arch replacement is complete resection of both the ascending aorta and the aortic arch where atherosclerotic lesions are commonly present in patients with atherosclerotic aneurysms. Ergin and colleagues [3] suggested that the presence of clots or atheroma in the aorta was a determinant of stroke during operation for aneurysms of the aortic arch. This indicates that the incidence of stroke can be reduced by complete resection of both the ascending aorta and aortic arch in which clots or atheroma are present even in the absence of aneurysms. Techniques for total arch replacement include the en bloc repair technique and the separated graft technique. The latter has the following advantages: First, total pump and SCP times are shorter than those necessary in en bloc repair [16]; second, atherosclerotic lesions that frequently develop near the origin of arch vessels can be completely resected; third, anastomosis can be performed at the intact distal site of the arch vessels where dissection has not extended; and finally, bleeding at the site of arch vessel anastomosis can be readily controlled.

Vascular grafts used for the separated graft technique had three branches in procedures performed before 1993 and four branches in those performed in 1993 and afterwards. Arch reconstruction using a graft with four limbs has the following advantages: First, ischemia in the LSA region can be maximally reduced, and second, antegrade perfusion through the fourth branch after completion of distal graft anastomosis under circulatory arrest can prevent embolism that may occur due to retrograde perfusion through the femoral artery or poor perfusion of the organ due to perfusion of the false lumen.

We have performed simultaneous total arch replacement in the following selected patients with acute type A aortic dissection [16, 17]: acute aortic arch dissection with a tear in the aortic arch; acute type A aortic dissection with a tear in the descending aorta; rupture or massive false lumen of the aortic arch or both; compromise of arch vessels; coexistent aortic arch aneurysm; and young patients with congenital aortic abnormalities, especially those with Marfan syndrome, who have no serious preoperative complications. Careful selection of patients for total arch replacement should reduce the risk of repeat operation in the late postoperative period and improve the late results.

Considering that patients with acute aortic dissection accounted for about one-third of our series, the hospital mortality rate of 12.7% is comparable with rates reported in a large number of recent studies by others, despite differences in arch reconstruction technique. Mortality rates were 10% in Svensson and colleagues’ study using HCA [2], 15% in Ergin and colleagues’ study using HCA [3], and 6.7% in Coselli and colleagues’ study using HCA or RCP [5]. Our data suggest that in-hospital mortality after total arch replacement is primarily affected by the preoperative state of the patients.

Dossche and colleagues [11] reported transient neurologic dysfunction in 3.8% of patients after aortic arch reconstruction under SCP and suggested that preoperative hemodynamic instability and perioperative technical problems were independent determinants of that sequel. Ergin and colleagues [3] observed transient neurologic dysfunction in 19.3% after aortic arch repair under HCA and suggested advanced age, circulatory arrest time, and rupture as independent predictors. Similarly, Okita and colleagues [7] reported an incidence of transient neurologic dysfunction of 25.0% with RCA. Although Okita and colleagues suggested that transient neurologic dysfunction is not associated with in-hospital mortality, we think that such sequelae affect postoperative management and hospital stay, especially in aged patients. Some authors have speculated on the cause of transient neurologic dysfunction: Livesay and colleagues [18] suggested alterations in microcirculation or gaseous emboli during prolonged periods of rewarming. Ergin and colleagues [19] speculated that transient dysfunction is a clinical marker for insidious but significant neurologic injury associated with measurable long-term deficits in cerebral function. In our SCP, which employs moderate hypothermia at 22°C, the rewarming period is shorter than that in HCA or RCP, which necessitates temperatures of 15° to about 18°C; the diminished rewarming period may reduce the incidence of subsequent transient neurologic dysfunction.

It is difficult to compare surgical outcomes under SCP, particularly the incidence of cerebral complications, with those under HCA or RCP because of the differences in patient background and operative technique. However, the incidence of stroke in our series (3.3%) was comparable with those in other studies that used HCA (0 to about 11%) [1–3], RCP (0 to about 12.5%) [4–7], or SCP (0 to about 5.4%) [8–11]. Ohmi and colleagues [20] reported a similarly high incidence of postoperative stroke after aortic arch repair using SCP in patients with preoperative intracranial and extracranial occlusive diseases. Svensson and colleagues [2] also reported a high incidence of stroke after operation under HCA in patients with a history of cerebrovascular disease. Therefore, in patients with old cerebral infarcts, further improvement in brain protection methods will be necessary.

In our series, the 5-year survival rate in the 220 patients treated by total arch replacement using the separated graft technique was 79%. This figure was higher than that of Svensson and colleagues [2] (65%), whose investigation included 656 patients operated upon using HCA.

In summary, selective cerebral perfusion, which basically can be used for unlimited periods to protect the brain, allows meticulous aortic arch reconstruction and complex and time-consuming total arch replacement. The separated graft technique may reduce mortality and morbidity in operations performed in patients with aneurysms of the aortic arch including acute aortic dissection and may eventually lead to improvement in late surgical results.

	Appendix

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Preoperative and perioperative variables included in analysis

Age Sex Early series (vs late series) Marfan syndrome Acute aortic regurgitation Annuloaortic ectasia Dissection Acute dissection Emergency rupture Shock Coronary ischemia History of acute myocardial infarction Chronic obstructive pulmonary disease Tamponade Renal/mesenteric ischemia Leg ischemia Preoperative tracheal intubation Old cerebral infarct Renal failure Hemodialysis Previous cardiovascular operation Previous ascending aorta and aortic arch operation Left thoracotomy Extended replacement (ascending aorta, total arch, and proximal descending aorta) Concomitant mitral valve replacement or repair Concomitant aortic valve replacement Concomitant aortic valve suspension Elephant trunk Concomitant composite graft replacement Concomitant coronary artery bypass graft Pump time 300 minutes

^a Data are presented as number of cases/number of patients surviving the operation.

SCP = antegrade selective cerebral perfusion.

	References

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				H. Ogino, M. Ando, H. Sasaki, and K. Minatoya Total arch replacement using a stepwise distal anastomosis for arch aneurysms with distal extension Eur. J. Cardiothorac. Surg., February 1, 2006; 29(2): 255 - 257. [Abstract] [Full Text] [PDF]

				R. Gottardi, J. Lammer, M. Grimm, and M. Czerny Entire rerouting of the supraaortic branches for endovascular stent-graft placement of an aortic arch aneurysm Eur. J. Cardiothorac. Surg., February 1, 2006; 29(2): 258 - 260. [Abstract] [Full Text] [PDF]

				H. Yokoyama Reply to the Editor: J. Thorac. Cardiovasc. Surg., September 1, 2005; 130(3): 951 - 952. [Full Text] [PDF]

				D. Spielvogel, J. C. Halstead, M. Meier, I. Kadir, S. L. Lansman, R. Shahani, and R. B. Griepp Aortic Arch Replacement Using a Trifurcated Graft: Simple, Versatile, and Safe Ann. Thorac. Surg., July 1, 2005; 80(1): 90 - 95. [Abstract] [Full Text] [PDF]

				R.S. Bonser and D.K. Harrington Editorial comment Eur. J. Cardiothorac. Surg., July 1, 2005; 28(1): 102 - 103. [Full Text] [PDF]

M. Sasaki, A. Usui, M. Yoshikawa, T. Akita, and Y. Ueda Arch-first technique performed under hypothermic circulatory arrest with retrograde cerebral perfusion improves neurological outcomes for total arch replacement Eur. J. Cardiothorac. Surg., May 1, 2005; 27(5): 821 - 825. [Abstract]