title: Technical advances in total aortic arch replacement.
abstract: BACKGROUND
  We compared the effects of using hypothermic circulatory arrest (HCA) alone, HCA combined with selective cerebral perfusion (SCP), and use of SCP with a trifurcated graft (T) on outcome after aortic arch repair.
  
  
  METHODS
  One hundred fifty patients, median age 66 years (range, 27 to 85), underwent total arch replacement between 1988 and 2002; 75 were female. We retrospectively compared the results of three patient groups roughly comparable with regard to preoperative risk factors: 45 patients using HCA beginning in 1988; 67 patients using HCA/SCP beginning in 1994; and 38 patients utilizing a trifurcated arch graft in conjunction with SCP through the axillary artery (HCA/SCP/T) since 2000. The groups were well matched with regard to median age (66, 68, and 66 years), urgency (emergent 11%, 13%, 5%; urgent 24%, 9%, 18%; and elective 64%, 78%, 76%), and several other known risk factors (p = not significant).
  
  
  RESULTS
  An adverse outcome-hospital death or permanent stroke-occurred in 14%: in 16% with HCA, in 16% with HCA/SCP, and in 8% with HCA/SCP/T. Transient neurologic dysfunction among patients surviving without stroke was lower with HCA/SCP/T (11%) than with HCA (33%) or HCA/SCP (17%). Mean duration of HCA was 52 +/- 16 minutes with HCA alone versus 45 +/- 10 minutes with HCA/SCP and 31 +/- 7 minutes with HCA/SCP/T (p < 0.0001 for groups HCA and HCA/SCP combined versus HCA/SCP/T). Mean duration of SCP was 57 +/- 25 minutes with HCA/SCP versus 62 +/- 24 minutes with HCA/SCP/T (p = not significant). Comparison of the groups of patients who had comparable preoperative risk factors for adverse outcome showed a trend toward lower adverse outcome and transient neurologic dysfunction rates using HCA/SCP/T; a significant reduction in respiratory (p < 0.001), infectious (p = 0.015) and cardiac (p = 0.005) complications in HCA/SCP/T compared with the earlier groups; and significantly shorter durations of intensive care (p < 0.0001) and hospitalization (p = 0.004).
  
  
  CONCLUSIONS
  Our results suggest that HCA/SCP is superior to HCA alone for preventing cerebral injury during operations on the aortic arch. By further reducing embolic risk as well as duration of HCA, HCA/SCP/T with axillary artery cannulation may be the optimal technique for averting adverse outcomes, reducing complications, and shortening hospital stay after aortic arch repair.
authors.affiliation: Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York University, New York, New York, USA. ju.strauch@gmx.de
authors.forename: Justus T
authors.initials: JT
authors.lastname: Strauch
authors.forename: David
authors.initials: D
authors.lastname: Spielvogel
authors.forename: Alexander
authors.initials: A
authors.lastname: Lauten
authors.forename: Jan D
authors.initials: JD
authors.lastname: Galla
authors.forename: Steven L
authors.initials: SL
authors.lastname: Lansman
authors.forename: Kirk
authors.initials: K
authors.lastname: McMurtry
authors.forename: Randall B
authors.initials: RB
authors.lastname: Griepp
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001013:Aorta, Thoracic / Q000601:surgery*; D001015:Aortic Arch Syndromes / Q000401:mortality / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation; D001921:Brain / Q000098:blood supply*; D001925:Brain Damage, Chronic / Q000401:mortality / Q000517:prevention & control; D002545:Brain Ischemia / Q000401:mortality / Q000517:prevention & control; D002544:Cerebral Infarction / Q000401:mortality / Q000517:prevention & control; D003131:Combined Modality Therapy; D005260:Female; D006324:Heart Arrest, Induced; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D011183:Postoperative Complications / Q000401:mortality / Q000517:prevention & control; D012189:Retrospective Studies; D012307:Risk Factors; D015996:Survival Rate