title: Outcomes of Aortic Arch Replacement Performed Without Circulatory Arrest or Deep Hypothermia.
abstract: BACKGROUND
  Aortic arch replacement using standard techniques, including deep hypothermic circulatory arrest and selective antegrade cerebral perfusion, is still associated with significant mortality and cerebral morbidity. We have previously described the "branch-first" technique that avoids circulatory arrest or profound hypothermia with excellent outcomes. We now describe our clinical experience with a larger cohort of patients as well as follow-up of our earlier results. We also describe a further technical simplification to this technique.
  
  
  METHODS
  From 2005 to 2010, 43 patients underwent a "branch-first continuous perfusion" technique for aortic arch replacement. In this technique, arterial perfusion is peripheral, usually by femoral inflow. Disconnection of each arch branch and anastomosis to a perfused trifurcation graft proceeds sequentially from the innominate to the left subclavian artery, with uninterrupted perfusion of the heart and viscera by the peripheral cannula. In the first cohort perfusion to the trifurcation graft was by right axillary cannulation. Since 2009, a modification was introduced such that perfusion is supplied directly by a sidearm on the trifurcation graft. This was used in the last 18 patients of this series. After reconstruction of the debranched arch and ascending aorta, the common stem of the trifurcation graft is anastomosed to the arch graft. In this series, there were 27 males, and mean age was 63 ± 13 years. Fifteen cases (35%) were performed with urgent/emergent priority. Nineteen patients (44%) were operated for aortic dissection, and the remainder for aneurysms. Seven patients (16%) had previously undergone a cardiac surgical procedure.
  
  
  RESULTS
  There were two (4.7%) early mortalities while one patient (2.3%) experienced a permanent stroke. One patient (2%) required mechanical support while three (7%) required hemofiltration for renal support. Extubation was achieved within 24 hours in 21 patients (49%) while 19 (42%) were discharged from the Intensive Care Unit (ICU) within two days. Eight patients (19%) did not require any transfusion of red cells or platelets. Mean follow-up duration was 21 ± 19 months and was 100% complete. At three years, survival was 95 ± 3.2%. No patients required subsequent aortic reoperation during this early follow-up period.
  
  
  CONCLUSIONS
  This modified branch-first continuous perfusion technique brings us closer to the goal of arch surgery without cerebral or visceral circulatory arrest and the morbidity of deep hypothermia. Our early experience is encouraging although greater numbers and longer follow-up will reveal the full potential of this approach.
authors.affiliation: Department of Cardiac Surgery, Austin Hospital, University of Melbourne, Victoria, Australia;
authors.forename: Nisal K
authors.initials: NK
authors.lastname: Perera
authors.affiliation: Department of Cardiac Surgery, Austin Hospital, University of Melbourne, Victoria, Australia;
authors.forename: William Y
authors.initials: WY
authors.lastname: Shi
authors.affiliation: Department of Cardiac Surgery, Austin Hospital, University of Melbourne, Victoria, Australia;
authors.forename: Rhiannon S
authors.initials: RS
authors.lastname: Koirala
authors.affiliation: Department of Cardiac Surgery, Austin Hospital, University of Melbourne, Victoria, Australia;
authors.forename: Sean D
authors.initials: SD
authors.lastname: Galvin
authors.affiliation: Department of Anaesthesia, Austin Hospital, University of Melbourne, Victoria, Australia.
authors.forename: Peter R
authors.initials: PR
authors.lastname: McCall
authors.affiliation: Department of Cardiac Surgery, Austin Hospital, University of Melbourne, Victoria, Australia;
authors.forename: George
authors.initials: G
authors.lastname: Matalanis
keywords: Aortic arch; Aortic surgery; Cerebral protection