title: Total arch replacement using selective antegrade cerebral perfusion as the neuroprotection strategy.
abstract: BACKGROUND
  Optimal neuro-protection strategy in aortic arch surgery is a controversial issue. The present study reported surgical outcomes of total arch replacement using selective antegrade cerebral perfusion (SACP).
  
  
  METHODS
  From January 2002 to December 2012, 438 consecutive patients (mean age 69.1±13.4 years) underwent total arch replacement using SACP through a median sternotomy. Acute aortic dissection was present in 86 patients (18.3; 80 type A, 6 type B) and shaggy aorta in 36 (8.2%). Emergent/urgent surgery was required in 144 (32.9%). Our current approach included: (I) meticulous selection of arterial cannulation site and type of arterial cannula; (II) selective antegrade cerebral perfusion; (III) maintenance of minimal tympanic temperature between 20 and 23 °C; (IV) early re-warming after distal anastomosis; and (V) maintaining fluid balance below 1,000 mL during cardiopulmonary bypass. A woven Dacron four branch graft was used in all patients.
  
  
  RESULTS
  Overall hospital mortality was 4.6% (20/438). Hospital mortality was 9.7% (14/144) in urgent/emergent surgery and 2.0% (6/294) in elective cases. Permanent neurological deficit occurred in 5.3% (23/438) of patients. Prolonged ventilation was necessary in 58 patients (13.2%). Multivariate analysis demonstrated that risk factors for hospital mortality were octogenarian (OR 4.45, P=0.03), brain malperfusion (OR 23.52, P=0.002) and cardiopulmonary bypass time (OR 1.07, P=0.04). The follow-up was completed in 97.9% with mean follow up of 2.3±2.3 years. Survival at 5 and 10 years after surgery was 79.6±3.3% and 71.2±5.0% respectively. In the acute type A dissection group, 10-year survival was 96.8±2.9%, while in the elective non-dissection group 5- and 10-year survival were 81.4±7.2% and 77.0±5.9% respectively.
  
  
  CONCLUSIONS
  Our current approach for total aortic arch replacement utilizing SACP was associated with low hospital mortality and morbidities leading to favorable long-term outcome.
authors: Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan.
authors: Yutaka
authors: Y
authors: Okita
authors: Kenji
authors: K
authors: Okada
authors: Atsushi
authors: A
authors: Omura
authors: Hiroya
authors: H
authors: Kano
authors: Hitoshi
authors: H
authors: Minami
authors: Takeshi
authors: T
authors: Inoue
authors: Toshihito
authors: T
authors: Sakamoto
authors: Shunsuke
authors: S
authors: Miyahara
authors: Tomonori
authors: T
authors: Shirasaka
authors: Katsuhiro
authors: K
authors: Yamanaka
authors: Taimi
authors: T
authors: Ohara
authors: Yoshikatsu
authors: Y
authors: Nomura
authors: Hidekazu
authors: H
authors: Nakai
keywords: Aortic arch surgery; antegrade cerebral perfusion; moderate hypothermic circulatory arrest; total arch replacement
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