Separate grafts or en bloc anastomosis for arch vessels reimplantation to the aortic arch.
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.
Di Eusanio
Marco
M
Department of Cardiac Surgery, "GM Lancisi" Hospital, Ancona, Italy. m_dieus@hotmail.com
Schepens
Marc A A M
MA
Morshuis
Wim J
WJ
Dossche
Karl M
KM
Kazui
Teruhisa
T
Ohkura
Kazuhiro
K
Washiyama
Naoki
N
Di Bartolomeo
Roberto
R
Pacini
Davide
D
Pierangeli
Angelo
A
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