title: Total arch replacement using antegrade cerebral perfusion.
abstract: OBJECTIVE
  The technical details of total arch replacement using antegrade cerebral perfusion are presented.
  
  
  METHODS
  From January 2002 to May 2012, 423 consecutive patients (mean age, 69.2 ± 13.1 years) underwent total arch replacement using antegrade selective cerebral perfusion through a median sternotomy. Acute aortic dissection was present in 81 patients (19.1%; 75 type A, 6 type B), and a shaggy aorta was present in 37 patients (8.7%). Emergency/urgent surgery was required in 135 patients (31.9%). Our current approach included meticulous selection of the arterial cannulation site and type of arterial cannula, antegrade selective cerebral perfusion, maintenance of the minimal tympanic temperature between 20 °C and 23 °C, early rewarming immediately after distal anastomosis, and maintenance of the fluid balance at less than 1000 mL during cardiopulmonary bypass. A woven Dacron 4-branch graft was used in all patients.
  
  
  RESULTS
  The overall hospital mortality was 4.5% (19/423): 9.6% (13/135) in urgent/emergency surgery cases and 2.1% (6/288) in elective cases. Permanent neurologic deficits occurred in 3.3% patients (14/423). Prolonged ventilation was necessary in 57 patients (13.4%). A multivariate analysis demonstrated the risk factors for hospital mortality to be age (octogenarian; odds ratio, 4.45; P = .02), brain malperfusion (odds ratio, 22.5; P = .002), and cardiopulmonary bypass time (odds ratio, 1.06; P = .04). The follow-up was completed in 97.2% of patients (mean, 29 ± 27; 1-126) and included 2.3 patients per year. Survival at 5 and 10 years after surgery was 79.6% ± 3.3% and 71.2% ± 5.0%, respectively. In the acute A dissection group, the 10-year survival was 96.6% ± 2.4%. In the elective nondissection group, the 5- and 10-year survivals were 80.3% ± 4.2% and 76.1% ± 5.7%, respectively.
  
  
  CONCLUSIONS
  Our current approach for total aortic arch replacement is associated with low hospital mortality and morbidity, thus leading to a favorable long-term outcome.
authors.affiliation: Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan. yokita@med.kobe-u.ac.jp
authors.forename: Yutaka
authors.initials: Y
authors.lastname: Okita
authors.forename: Kenji
authors.initials: K
authors.lastname: Okada
authors.forename: Atsushi
authors.initials: A
authors.lastname: Omura
authors.forename: Hiroya
authors.initials: H
authors.lastname: Kano
authors.forename: Hitoshi
authors.initials: H
authors.lastname: Minami
authors.forename: Takeshi
authors.initials: T
authors.lastname: Inoue
authors.forename: Shunsuke
authors.initials: S
authors.lastname: Miyahara
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D001013:Aorta, Thoracic / Q000503:physiopathology / Q000601:surgery*; D001018:Aortic Diseases / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D002560:Cerebrovascular Circulation; D017558:Elective Surgical Procedures; D004630:Emergencies; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D010477:Perfusion / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D011093:Polyethylene Terephthalates; D011183:Postoperative Complications / Q000401:mortality / Q000601:surgery; D011474:Prosthesis Design; D012086:Reoperation; D012307:Risk Factors; D056346:Sternotomy; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D011093:Polyethylene Terephthalates