Arch-first technique performed under hypothermic circulatory arrest with retrograde cerebral perfusion improves neurological outcomes for total arch replacement.
OBJECTIVE
From 1998, we have adopted the arch first technique (reconstruction of arch vessels first and distal anastomosis second) instead of the distal anastomosis first technique for total arch replacement. The aim is to reduce the period of deep hypothermic circulatory arrest and the retrograde cerebral perfusion time. We evaluate the surgical results of the arch first technique.


METHODS
The arch first technique was used in 50 cases (38 male and 12 female), of average age 68 years, from 1998 to 2003. There were 33 true aneurysms and 10 chronic and seven acute type A dissections. Clinical results were evaluated and compared with the distal first technique used in 24 cases operated on between 1992 and 1998. These were 14 males and 10 females, with an average age of 68 years. There were 16 true aneurysms, and three chronic and five acute aortic dissections.


RESULTS
For the arch first technique there is a significantly shorter circulatory arrest time (32 vs. 72min, P<0.0001), but similar body ischemic times (76 vs. 72min, N.S.). With the arch first technique, all but two patients awoke within 24h, with an average delay of 9.3h. In the distal first technique, two patients did not awaken and three patients showed delayed awakening, with an average awakening time of 24h. The arch first technique led to one hospital death (2%), due to residual aneurysm rupture. Reversible ischemic neurological deficit (RIND) was complicated in three cases (6%), but no stroke occurred during operation. In the distal first technique there were four strokes, one RIND and three hospital deaths (12.5%). The arch first technique gave a significantly lower intra-operative stroke rate (P=0.0030) and smaller hospital mortality (P=0.0615). The arch first technique led to five late deaths, with an 84.5% 3 year survival rate, and the distal first technique led to six late deaths with a 59.1% 3-year survival rate.


CONCLUSIONS
The arch first technique is clearly superior to the conventional distal first technique in surgical mortality and morbidity regarding neurological outcome, and provides a higher survival rate and better quality of life. The arch first technique is an excellent method for total arch replacement.
Sasaki
Michio
M
Department of Cardio-Thoracic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa-ku, Nagoya 466-8550, Japan.
Usui
Akihiko
A
Yoshikawa
Masaharu
M
Akita
Toshiaki
T
Ueda
Yuichi
Y
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000714:Anastomosis, Surgical; D000784:Aortic Dissection / Q000401:mortality / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000401:mortality / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000401:mortality; D002560:Cerebrovascular Circulation; D005260:Female; D006324:Heart Arrest, Induced; D006801:Humans; D007036:Hypothermia, Induced; D007431:Intraoperative Complications; D008297:Male; D008875:Middle Aged; D010477:Perfusion; D012189:Retrospective Studies; D020521:Stroke / Q000209:etiology / Q000401:mortality