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Aortic Arch Surgery:

Techniques and Results

Leonard N. Girardi, M.D.

O. Wayne Isom Professor of Cardiothoracic Surgery

Weill Cornell Medical College

Director, Thoracic Aortic Surgery

New York Presbyterian Hospital

Thoracic Aortic Aneurysms:

Yearly Rupture, Dissection or Death

12

14

16

18

20

% Yearly Rate

0

2

4

6

8

10

12

4.0 - 4.9 5.0 - 5.9 >6.0

Aneurysm Size

% Yearly Rate

Davies, Ann Thor Surg, 2002

Arch Repair

Indications for Surgery

• Diameter greater than 5.5 cm

• Growth greater than 1 cm per year

• Symptomatic aneurysm

• Type A dissection with arch involvement

• Ascending or Descending aneurysm with arch

extension

Arch RepairProfound Hypothermic Circulatory Arrest

15

20Mortality = 12%

CVA = 7%

0

5

10

0 15 30 45 60

minutes of PHCA

% CVA

Cerebral Protection

Prolonged cooling Topical cooling

Cerebral Protection

Barbiturates Speed

Retrograde cerebral perfusion

Aortic Arch Surgery

Retrograde Cerebral Perfusion

Cooling Period

• Pack head in ice

• Minimum of 30 minute

• Cerebral oxymetry

• Bladder temp of 18o C

• Methylhexital (1 gm) prior to circulatory arrest

Retrograde Cerebral Perfusion

• Initiate circulatory arrest, steep Trendelenberg

• Examine anatomy then initiate RCP

• Flows 300 - 500 cc/min• Flows 300 - 500 cc/min

• CVP 20 - 25 mmHg, examine left innominate vein

• Move cannula to one-branch graft for antegrade

perfusion

• Keep RCP on for initial return to CBP

• Maintain gradient of 10o C during warming

Retrograde Cerebral Perfusion

Advantages

• Simplicity and speed

• Maintain cerebral hypothermia•

• Prevention of air and debris emboli

• Flush toxic byproducts of metabolism

• No manipulation of the great vessels

Retrograde Cerebral Perfusion

Disadvantages

• Need for profound hypothermia

• ? Delivery of metabolic substrate• ? Delivery of metabolic substrate

• Effectiveness in cases of prolonged circulatory arrest

Cerebral Protection

Barbiturates ? Speed

Cerebral Protection

Moderate hypothermia

Antegrade cerebral perfusion

Antegrade Cerebral Perfusion

Intraoperative Management

• Degree of cooling varies: 20 C – 25 C

• Clamp innominate, rely on circle of Willis• Clamp innominate, rely on circle of Willis

• Balloon tip catheters into innominate and LCCA

• Flow ~ 10 cc/kg/min

• Maintain MAP ~ 50 mmHg

Antegrade Cerebral Perfusion

Advantages

• Maintain cerebral perfusion during circulatory arrest

• Potential advantage of less hypothermia

• ? Improved cerebral protection for complex or

prolonged arch reconstruction

Antegrade Cerebral Perfusion

Disadvantages

• Complexity and time

• Reliance of intact circle of Willis• Reliance of intact circle of Willis

• Great vessel manipulation, ? Increase embolic events

• Cluttered operative field if choose to use balloon tip

catheters

Arch RepairTechniques

• Hemiarch

• Total Arch• Total Arch

• Total Arch with Elephant Trunk

• Total Arch/Debranching

Aortic Arch Replacement

Primary Procedure N=870

- Hemiarch 497

- Total arch/island 158

- Total arch/elephant trunk 114

- Total arch/debranching 101

Additional Procedures

Asc tube graft 497 Rep IAA 33

CVG/Valve Sp 373 Desc An 47

CABG 207 ASD 29

AoV repair 350 MVR/Rep 91

AVR 147

Surgery of the Aortic Arch

Weill Cornell Medical Center

Complications N = 870

TND 10

CVA 7

Delayed/embolic event 3Delayed/embolic event 3

Tracheostomy 28

Myocardial failure 5

Hemodialysis 14

Reoperation for bleeding 33

Mortality 18

Open Aortic Arch Repair

Author N Year % CVA % Mortality

Czerny 369 2003 5.0 11.5

Safi 218 2004 2.7 8.7Safi 218 2004 2.7 8.7

Kucuker 181 2005 2.2 1.7

Spielvogel 150 2007 4.0 4.6

Sundt 347 2008 8.4 8.9

Leshnower 344 2010 3.6 7.0

Open Arch RepairFreedom From Reoperation

Endovascular

Aortic Arch Repair

Author N Year % CVA % Mortality

Bergeron 25 2006 8.0 8.0

Schumacher 25 2006 4.0 20.0

Czerny 27 2007 0.0 7.4

Melissano 26 2007 7.7 7.7

Weigang 26 2009 3.8 15.4

Holt 26 2010 3.8 3.8

Milewski 27 2010 3.7 11.1

Kulik, Ann Thorac Surg, 2011

Conclusions

• Aortic aneurysms and dissections remain lethal diseases, early diagnosis is critical to survival

• Consistent surgical success can be achieved in high volume centers utilizing a team approach

• RCP and ACP provide excellent cerebral protection, neurologic injury should be minimal

• Hybrid arch repair is appropriate for very high-risk patients

• Open repair remains the gold standard