title: Separate grafts or en bloc anastomosis for arch vessels reimplantation to the aortic arch.
abstract: BACKGROUND
  This study compares the results of the separated graft technique and the en bloc technique as a method of arch vessels reimplantation during surgery of the aortic arch and determines the predictive risk factors associated with hospital mortality and adverse neurologic outcome during aortic arch repair.
  
  
  METHODS
  Between October 1995 and March 2002, 352 patients (mean age 64.9 +/- 11.3 years; urgent status: 49/352 [13.9%]) underwent surgery of the aortic arch using the separated graft technique (group A: n = 230 [65.3%]) and the en bloc technique (group B: n = 122 [34.7%]) to reimplant the arch vessels. An aortic arch replacement was performed in 32 patients (9.1%), an ascending aorta and arch replacement in 222 patients (53.1%), an aortic arch and descending aorta replacement in 16 patients (4.5%), and a complete replacement of the thoracic aorta in 82 patients (23.3%). Brain protection was achieved by means of antegrade selective cerebral perfusion in all patients. The mean cardiopulmonary bypass time was 204.8 +/- 61.9 minutes (group A: 199.7 +/- 57.0 minutes; group B: 214.5 +/- 69.4 minutes; p = 0.033), the mean myocardial ischemic time was 121.5 +/- 43.2 minutes (group A: 116.7 +/- 38.9 minutes; group B: 130.80 +/- 49.4 minutes; p = 0.003), and the mean antegrade selective cerebral perfusion time was 84.5 +/- 36.4 (group A: separated graft technique 91.3 +/- 36.3 minutes; group B: 70.6 +/- 32.7 minutes; p = 0.000).
  
  
  RESULTS
  Overall hospital mortality was 6.8% (group A: 6.5%; group B: 7.4%; p = not significant [NS]). The permanent neurologic dysfunction rate was 3.5% (group A: 4.0%; group B: 2.5%; p = NS). The transient neurologic dysfunction rate was 5.4% (group A: 5.5%; group B: 5.2%, p = NS). Postoperative systemic morbidity was similar in the two groups. A logistic regression analysis revealed preoperative cardiac tamponade (p = 0.011; odds ratio [OR] = 5.9) and cardiopulmonary bypass time (p = 0.010; OR = 1.01/min) to be independent predictors of hospital mortality. None of the analyzed preoperative variables were associated with an increased risk of permanent neurologic dysfunction. Age more than 70 years old (p = 0.029, OR = 5.7), myocardial revascularization (p = 0.001, OR = 2.9), and pump time (p = 0.013, OR = 1.01/min) were indicated as independent predictors of transient neurologic dysfunction by logistic regression.
  
  
  CONCLUSIONS
  Antegrade selective cerebral perfusion was confirmed to be a safe method of cerebral protection allowing complex aortic arch operations to be performed with acceptable results in terms of hospital mortality and neurologic outcome. The separated graft technique had no adverse impact on hospital mortality and morbidity.
authors.affiliation: Department of Cardiac Surgery, "GM Lancisi" Hospital, Ancona, Italy. m_dieus@hotmail.com
authors.forename: Marco
authors.initials: M
authors.lastname: Di Eusanio
authors.forename: Marc A A M
authors.initials: MA
authors.lastname: Schepens
authors.forename: Wim J
authors.initials: WJ
authors.lastname: Morshuis
authors.forename: Karl M
authors.initials: KM
authors.lastname: Dossche
authors.forename: Teruhisa
authors.initials: T
authors.lastname: Kazui
authors.forename: Kazuhiro
authors.initials: K
authors.lastname: Ohkura
authors.forename: Naoki
authors.initials: N
authors.lastname: Washiyama
authors.forename: Roberto
authors.initials: R
authors.lastname: Di Bartolomeo
authors.forename: Davide
authors.initials: D
authors.lastname: Pacini
authors.forename: Angelo
authors.initials: A
authors.lastname: Pierangeli
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000714:Anastomosis, Surgical; D001013:Aorta, Thoracic / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000601:surgery; D019917:Blood Vessel Prosthesis Implantation / Q000379:methods*; D002560:Cerebrovascular Circulation; D005260:Female; D006324:Heart Arrest, Induced; D017052:Hospital Mortality; D006801:Humans; D007036:Hypothermia, Induced; D008297:Male; D001523:Mental Disorders / Q000209:etiology; D008875:Middle Aged; D016343:Monitoring, Intraoperative; D011183:Postoperative Complications; D012307:Risk Factors; D020521:Stroke / Q000209:etiology