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Ann Thorac Surg 2004;77:581-590
© 2004 The Society of Thoracic Surgeons
a Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York University, New York, New York, USA
* Address reprint requests to Dr Strauch, Mount Sinai School of Medicine, Department of Cardiothoracic Surgery, One Gustave L. Levy Pl, PO Box 1028, New York, NY 10029, USA.
e-mail: ju.strauch{at}gmx.de
Presented at the Thirty-ninth Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 31–Feb 2, 2003.
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Abstract |
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 Top Abstract IntroductionPatients and methodsResultsCommentConclusionsDiscussionReferences |
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METHODS: One hundred fifty patients, median age 66 years (range, 27 to 85), underwent total arch replacement between 1988 and 2002; 75 were female. We retrospectively compared the results of three patient groups roughly comparable with regard to preoperative risk factors: 45 patients using HCA beginning in 1988; 67 patients using HCA/SCP beginning in 1994; and 38 patients utilizing a trifurcated arch graft in conjunction with SCP through the axillary artery (HCA/SCP/T) since 2000. The groups were well matched with regard to median age (66, 68, and 66 years), urgency (emergent 11%, 13%, 5%; urgent 24%, 9%, 18%; and elective 64%, 78%, 76%), and several other known risk factors (p = not significant).
RESULTS: An adverse outcome—hospital death or permanent stroke—occurred in 14%: in 16% with HCA, in 16% with HCA/SCP, and in 8% with HCA/SCP/T. Transient neurologic dysfunction among patients surviving without stroke was lower with HCA/SCP/T (11%) than with HCA (33%) or HCA/SCP (17%). Mean duration of HCA was 52 ± 16 minutes with HCA alone versus 45 ± 10 minutes with HCA/SCP and 31 ± 7 minutes with HCA/SCP/T (p < 0.0001 for groups HCA and HCA/SCP combined versus HCA/SCP/T). Mean duration of SCP was 57 ± 25 minutes with HCA/SCP versus 62 ± 24 minutes with HCA/SCP/T (p = not significant). Comparison of the groups of patients who had comparable preoperative risk factors for adverse outcome showed a trend toward lower adverse outcome and transient neurologic dysfunction rates using HCA/SCP/T; a significant reduction in respiratory (p < 0.001), infectious (p = 0.015) and cardiac (p = 0.005) complications in HCA/SCP/T compared with the earlier groups; and significantly shorter durations of intensive care (p < 0.0001) and hospitalization (p = 0.004).
CONCLUSIONS: Our results suggest that HCA/SCP is superior to HCA alone for preventing cerebral injury during operations on the aortic arch. By further reducing embolic risk as well as duration of HCA, HCA/SCP/T with axillary artery cannulation may be the optimal technique for averting adverse outcomes, reducing complications, and shortening hospital stay after aortic arch repair.
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Introduction |
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TopAbstractIntroductionPatients and methodsResultsCommentConclusionsDiscussionReferences |
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Clinical studies have resulted in identifying some of the preoperative and operative variables that put patients at especially high risk of adverse outcome and more subtle neurologic injury. Among these are emergency operation and the presence of clot or atheroma in the aorta, but various factors related to techniques for cerebral protection also play an important role. A consensus is emerging that the optimal surgical treatment for extensive thoracic aortic aneurysm or dissection involving the transverse aortic arch involves using for cerebral protection either hypothermic antegrade selective cerebral perfusion (SCP) or a combination of hypothermic circulatory arrest (HCA) and SCP during aortic arch replacement. Use of HCA alone may result in suboptimal cerebral protection if the reconstruction is prolonged: HCA duration more than 40 minutes is associated with an increased stroke rate and HCA for more than 60 minutes results in decreased survival [6]. Furthermore, close scrutiny of cerebral recovery—including use of psychometric testing—has revealed that HCA duration more than 25 minutes is significantly associated with the occurrence of transient neurologic dysfunction in the immediate postoperative period and with prolonged albeit subtle cognitive deficits persisting many weeks postoperatively [7].
To shorten the required interval of HCA, we have gradually incorporated use of SCP into our technique for aortic arch repair. Although a technique using SCP exclusively has been advocated by others, we have been concerned about this approach because of the risk of embolization associated with blind cannulation of the cerebral vessels in the often severely atherosclerotic aortas of patients requiring aortic arch surgery [8].
The current retrospective study was undertaken to compare three techniques: our original technique, the use of HCA alone, and two techniques involving the use of SCP combined with HCA. The first SCP technique involves perfusion of a patch graft containing the arch vessels (HCA/SCP) and our current technique involves perfusion of a trifurcated graft (T) sewn into the arch vessels cephalad to their attachment to the arch (HCA/SCP/T). We compare the results of these different surgical approaches on adverse outcome and on neurologic and other complications after aortic arch repair.
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Patients and methods |
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TopAbstractIntroductionPatients and methodsResultsCommentConclusionsDiscussionReferences |
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Various preoperative characteristics of the remaining 150 patients are seen in Tables 1 and 2. There were 75 women and 75 men. Median age was 66 years (range, 27 to 85). The underlying etiology of the aneurysm was arteriosclerosis in 101 patients (67%), acute dissection in 17 (11%), chronic dissection in 21 (14%), and Marfan disease in 11 (7%). Forty-eight patients (32%) had undergone previous aortic surgery: a Bentall procedure and replacement of the proximal ascending aorta for acute type A dissection (n = 22); hemiarch replacement (n = 7); total aortic arch replacement (n = 4); aortic valve repair (n = 8); coronary artery bypass grafting ([CABG] n = 4), and thoracoabdominal aortic aneurysm repair (n = 3).
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The three patient groups operated on with differing techniques were well matched with regard to mean age (62, 65, and 64 years) and urgency of operation (emergent 18%, 15%, 5%; urgent 24%, 9%, 18%; and elective 58%, 76%, 76%). Differences in preoperative findings were generally not significantly different among the groups although arteriosclerosis was significantly more prevalent as the etiology of aneurysms in the HCA/SCP/T group as was a history of coronary artery disease. A previous neurologic history was more prevalent in the HCA group. A history of hypertension was the most common preoperative finding (62%, 79%, 47%), followed by a history of smoking (60%, 69%, 47%) and of coronary artery disease (11%, 28%, 34%). The mean diameter of the aortic arch was 7.4 ± 1.4 cm (range, 4.8 to 10.2 cm) in patients in the HCA group versus 7.2 ± 1.4 cm (range, 4.8 to 12 cm) in the HCA/SCP group and 6.7 ± 1.6 cm (range, 4.5 to 10 cm) in the SCP/T group (p = not significant).
Surgical technique, HCA
Total arch repair was performed through a median sternotomy (Fig 1).
Cannulation for cardiopulmonary bypass (CPB) was undertaken through the femoral artery and right atrium. The techniques for achieving HCA have previously been described in detail [1, 9]. Briefly, cooling during CPB is carried out until an average core temperature of 11°C to 13°C is reached. HCA is not initiated until oxygen saturation is more than 95% in the jugular venous bulb indicating maximal metabolic suppression. The part of the operation requiring interruption of cerebral blood flow—anastomosis of a graft to the descending thoracic aorta and attachment of an island containing the brachiocephalic vessels to the side of the graft—is carried out during the interval of HCA, free of blood and cannulas.
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Surgical technique, HCA/SCP
For HCA/SCP (Fig 2)
aortic cannulation for CPB was through a femoral artery. A two-staged venous cannula was used for the right atrium. Deep HCA as described above was used in all patients. Aortic dissection was minimized during CPB to avoid dislodgement and embolization of loose material [10]. In all patients initiation of HCA was governed by jugular venous oxygen saturation and the head was packed in ice.
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The arch reconstruction was then undertaken using an ascending-to-descending conduit with an appropriately sized collagen-impregnated Dacron graft. The brachiocephalic graft was then attached in an end-to-side fashion. The arterial cannula was repositioned into the main graft for rewarming. A slow rewarming period of more than 1 hour was utilized. Circulatory support was terminated after reaching an acceptable body temperature (bladder, > 30°C, esophagus, > 36°C).
Surgical technique, HCA/SCP/T
Trifurcated graft implantation combined with HCA and SCP (Fig 3) was performed according to the technique described by Spielvogel and associates [12]. The right axillary artery was exposed and cannulated with a right angle wire-reinforced arterial catheter. Cardiopulmonary bypass and cooling were started after cannulation of the right atrium. The perfusate temperature was kept 10°C below the body core temperature. After carefully sizing the innominate, left carotid, and left subclavian arteries, a trifurcation graft was constructed. Generally a 14-mm graft with two 10-mm Hemashield side grafts or a 12-mm graft with two 8-mm Hemashield side grafts were selected (Boston Scientific, Wayne, NJ). Grafts used in this period were constructed in the operating room. The completion of this phase of the operation usually coincided with the end of core cooling: the esophageal temperature had dropped to 12°C to 15°C and the jugular bulb oxygen saturation was more than 95%. Again the head was packed in ice.
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The aortic arch was reconstructed during the period of SCP. The trifurcated graft was reflected off the operative field superiorly, allowing precise construction of the elephant trunk anastomosis. Later the trifurcated graft was joined by an end-to-side anastomosis to the ascending portion of the aortic reconstruction. Cerebral and upper extremity perfusion were not interrupted. After the graft-to-graft anastomosis was completed, the patient was actively rewarmed and weaned from mechanical support.
Analysis of results
Adverse outcome was defined as intraoperative or in-hospital death or occurrence of permanent neurologic injury. A stroke was considered permanent when the patient was discharged with residual neurologic symptoms.
Transient neurologic dysfunction was analyzed separately in all patients surviving the operation excluding those who had strokes or who never regained consciousness after surgery. Transient neurologic dysfunction was defined as postoperative confusion, agitation, delirium, prolonged obtundation or Parkinson-like symptoms, with no focal deficit in computed tomography or magnetic resonance imaging if these studies were available.
Data collection and statistical analysis
Medical records were reviewed for clinical variables including preoperative status, intraoperative data, and postoperative complications.
Statistical analysis was performed using SAS (SAS Institute Inc, Cary, NC) and STAT-EXACT (Cytel Software Corp, Cambridge, MA) statistical software. Values were expressed as mean ± standard deviation, medians and interquartile range (IQR), and for categorical variables as percentages. Chi-square tests, analysis of variance, and Kruskal-Wallis tests were used as appropriate. A p value less than 0.05 was considered significant.
The groups undergoing the three different types of operative procedures were first compared with regard to preoperative variables that judging from previous studies might impact significantly on outcome. The discovery that the groups differed with regard to patients with hemodynamic compromise before operation led us to eliminate these high-risk patients (5 from the HCA group and 1 from HCA/SCP) from the further analyses. A multiple logistic regression analysis was then done to look for risk factors relating to adverse outcome. Because of the small number of patients the statistical analyses regarding outcomes were carried out comparing the most recent group (HCA/SCP/T) with the two earlier groups combined.
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Results |
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TopAbstractIntroductionPatients and methodsResultsCommentConclusionsDiscussionReferences |
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There was also a significantly higher proportion of patients with atherosclerotic aneurysms—previously shown to be at higher risk for adverse outcome—in the HCA/SCP/T group of patients. In contrast to earlier studies, multiple logistic regression analysis of the patients in this study identified an etiology other than arteriosclerosis as a risk factor for adverse outcome, so it is not clear how to interpret this finding. Excluding etiology as a factor in the current study, the independent risk factors for stroke or death were, in accord with previous studies, female sex (p = 0.067), the presence of clot or atheroma (p = 0.02), and chronic obstructive pulmonary disease (p = 0.002); the groups did not differ significantly in the proportion of patients having any of these preoperative factors.
Adverse outcome
Adverse outcome occurred in 16% of patients undergoing HCA (7 of 45) and of patients undergoing HCA/SCP (11 of 67). It was lower with HCA/SCP/T: only 8% (3 of 38 patients) suffered death or permanent stroke. The adverse outcome of 16% in the two early groups combined was not significantly higher than the 8% in the HCA/SCP/T group (Table 3).
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Nine patients (13%) in the HCA/SCP group died during their hospital stay and included 1 intraoperative death due to aneurysm rupture. Death was related to cardiac failure in 3 patients; 2 patients suffered postoperative aneurysm rupture and 1 patient showed signs of mesenteric infarction. Two patients in the HCA/SCP group died of neurologic complications and 2 patients survived major stroke.
Only 2 deaths (5%) occurred in the HCA/SCP/T group before hospital discharge: 1 was related to diffuse neurologic injury and another was due to multiorgan failure on postoperative day 18. One patient in the HCA/SCP/T group survived major stroke. The patients with adverse outcome were early in the series (patients 1, 6, and 11).
Risk factors for adverse outcome by multiple logistic regression analysis of all 150 patients identified female sex, presence of clot or atheroma, and chronic obstructive pulmonary disease as risk factors for an adverse outcome in the group as a whole. For each of these high-risk groups of patients the trend was toward better results using HCA/SCP/T as shown in Table 4. Arteriosclerosis gradually became the most frequent etiology of aneurysms requiring total arch replacement. The results comparing the incidence of adverse outcome among patients with atherosclerosis in the three groups showed the same trend: HCA, 3 of 21 (14.3%); HCA/SCP, 7 of 49 (14.3%); and HCA/SCP/T, 1 of 31 (3.2%).
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Other major complications
As shown in Table 5,
respiratory failure—defined as the need for more than 48 hours of mechanical ventilation after surgery—was the most common complication in the HCA group, occurring in 22 patients (48%), and in the HCA/SCP group, in which 36 patients (54%) were affected. In contrast, respiratory failure occurred in only 4 patients (11%) in the HCA/SCP/T group. Postoperative respiratory failure was significantly less common in HCA/SCP/T patients compared with its incidence in the HCA and HCA/SCP groups combined (52%; p < 0.0001). Tracheostomy was necessary in 13 patients (29%) in the HCA group and 23 patients (34%) in the HCA/SCP group but only in 2 patients (5%) operated on using the trifurcated graft (HCA/SCP/T).
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Infectious complications were also significantly less frequent in the HCA/SCP/T group (3%) compared with the earlier two groups (19%; p = 0.015). As seen in Table 5 there was also a tendency toward a lower incidence of reoperation for bleeding in the HCA/SCP/T group but this did not attain significance (p = 0.12). Renal failure defined as a creatinine more than 1.2 mg/dL did not differ between groups; no patients who survived required dialysis at the time of discharge.
Cardiopulmonary bypass
Data describing extracorporeal circulation times and temperatures for the patients in the various groups are seen in Table 6.
The mean duration of CPB in the HCA group, in which deep HCA alone was used for cerebral protection, was 185 ± 62 minutes (range, 94 to 370); the mean duration of HCA was 52 ± 16 minutes (range, 19 to 83). In contrast the mean duration of HCA in the HCA/SCP group was slightly shorter at 45 ± 10 minutes (range, 24 to 74). The mean duration of SCP in this group was 57 ± 25 minutes (range, 20 to 153) and the duration of CPB was 226 ± 38 minutes (range, 147 to 307).
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The mean lowest esophageal temperatures did not differ between the groups: in the HCA group the mean was 12.0 ± 1.6°C (range, 8.7 to 15.1°C); in the HCA/SCP group it was 11.2 ± 1.0°C (range, 8.5 to 15.0°C); and in the HCA/SCP/T group it was 11.2 ± 0.8°C (range, 9.9 to 13.0°C). Mean bladder temperatures also did not show statistically significant differences between the groups, with a mean of 17.4 ± 2.3°C (range, 11.1 to 21.4°C) in the HCA group, 15.7 ± 2.4°C (range, 9.8 to 21.6°C) in the HCA/SCP group, and 15.8 ± 2.3°C (range, 10.1 to 22.6°C) in the HCA/SCP/T group.
Duration of hospitalization
The median duration of hospital stay (Table 7)
for HCA patients was 17 days (IQR 12 to 32); HCA/SCP patients had a median stay of 18 days (IQR 11 to 23); and patients undergoing HCA/SCP/T had a median stay of 14 days (IQR 9 to 16). The duration of hospital stay for HCA/SCP/T patients was significant shorter than for the groups HCA and HCA/SCP combined (median 17.5 days, p = 0.004).
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Comment |
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TopAbstractIntroductionPatients and methodsResultsCommentConclusionsDiscussionReferences |
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The successful use of profound HCA ushered in an era in which this technique was the most accepted method for cerebral protection during replacement of the aortic arch [17]. A number of surgeons have attested to the safety of HCA over the ensuing years although there is still ongoing discussion about the maximum time limit for safe arrest of the circulation and the appropriate temperature for prolonged HCA. Monitoring of jugular venous oxygen saturation, electroencephalogram and somatosensory evoked potentials make the technique safer. Nevertheless there remains an unsettling risk of cerebral damage as well as other complications using HCA as the only neuroprotective method. This is reflected in our study by the higher incidence of adverse outcome, 22%, during the period in which HCA alone was used. In addition 28% of HCA patients had transient neurologic dysfunction probably because the mean duration of HCA in this group was 53 minutes. The patients operated on using HCA alone also had relatively high rates of complications.
To avoid prolonged HCA, the use of SCP, long championed by Bachet and Kazui, is an appealing alternative. The goal of our specific SCP strategy has been to allow unhurried repair of the arch by delivering sufficient oxygenated flow to sustain hypothermic cerebral metabolism but without causing embolization of atherosclerotic debris as a result of cannulation and perfusion through diseased vessels. Thus we began by using a vascular graft attached to a circumferential patch of aorta around the cerebral vessels, allowing us to provide antegrade flow without excessive manipulation of the atherosclerotic origins of the arch vessels. The rate of adverse outcome using this method in the HCA/SCP patient group was reduced to 11%. The duration of HCA was shortened to 45 minutes and the transient neurologic dysfunction rate was lowered to 18%.
An even more marked diminution both in HCA duration and in adverse outcome has been achieved using the trifurcated graft approach, which allows anastomosis of the arch vessels cephalad to the area of most obvious atherosclerotic disease and therefore significantly decreases the risk of embolization. With this technique the HCA time has been reduced to a mean of 31 minutes. The rate of adverse outcome has also been reduced to 8% and the incidence of transient neurologic dysfunction to 11%.
Although dramatic, the reduction in adverse outcome and transient neurologic dysfunction in the small numbers of patients in the HCA/SCP/T group fails to reach statistical significance compared with the earlier groups. But it should be pointed out that all three cases of adverse outcome in the HCA/SCP/T group occurred quite early in the experience. Moreover, despite the small number of patients, we are able to demonstrate a highly significant reduction in the incidence of respiratory, cardiac, and infectious complications and in the length of both intensive care unit and hospital stay in the HCA/SCP/T group compared with the combined earlier groups. Although it could be argued that an excellent outcome in the most recent group of patients could be attributed to patient selection and nonspecific improvements in care, comparisons among the patients in the highest risk categories for adverse outcome as identified by logistic regression analysis show a pattern consistent with the idea that the HCA/SCP/T technique represents a significant advance.
The striking diminution in respiratory complications is probably multifactorial. In some patients an elephant trunk originates in the ascending aorta, thus avoiding any operative trauma to either the recurrent laryngeal or to the phrenic nerve. Improved postoperative neurologic function also allows earlier extubation and more efficient clearing of respiratory secretions. A reduction in bleeding complications, likely due to the smaller diameter of the anastomoses in the cerebral vessels compared with the patch graft required with the earlier techniques, may also result in better pulmonary recovery. The marked improvement in postoperative respiratory function using the HCA/SCP/T technique is especially encouraging in that many patients with aneurysms have chronic obstructive pulmonary disease, which has been identified as a highly significant risk factor for rupture of aneurysms as well as for adverse outcome after surgery with earlier techniques.
We are somewhat at a loss to explain the significant reduction in cardiac complications seen in the HCA/SCP/T group especially since this group has a significantly higher percentage of patients with coronary artery disease. But clearly the improved neurologic results and the significant reduction in virtually all significant postoperative complications in the HCA/SCP/T group has contributed to the significant diminution in time spent in the intensive care unit and in duration of hospitalization.
Kazui and colleagues [18] utilized a branched arch graft technique and SCP in 220 consecutive patients with total arch replacement: they had a 12.7% mortality rate, a 3.3% stroke rate, and a 6% incidence of transient neurologic dysfunction. A more contemporary series of 50 patients resulted in a reduction of the mortality rate to 2% with a stroke rate of 4% and a 4% incidence of transient neurologic dysfunction [19]. Our permanent stroke rate of 4% and mortality rate of 4% compare favorably with the results of other groups using similar techniques [4, 19, 20].
Our approach to cerebral protection has evolved based on clinical and laboratory studies. We have found that periods of HCA less than 30 minutes are well tolerated even in elderly patients and patients with cerebrovascular disease if sufficient periods of core cooling (more than 30 minutes) are utilized and temperatures are sufficiently low (between 11°C and 14°C in the esophagus). The HCA is not implemented until the jugular bulb saturation is more than 95% indicating maximal metabolic suppression [21]. With current reconstructive techniques, the period of HCA is often quite brief and one could argue that shorter intervals of core cooling and higher temperatures before HCA with associated shorter CPB times might be adequate [4]. But our data, which suggest that even profound HCA for intervals more than 30 minutes results in subtle changes in late psychometric testing, inspire caution.
Avoiding cerebral embolization may be of even greater importance. In our current series none of the 7 patients with clot or atheroma in the aorta—who are among those at highest risk for embolization—had an adverse outcome. We advocate cannulation for arterial perfusion through direct access to the right or left axillary arteries. Cannulation of the femoral artery for CPB should be avoided as the atherosclerotic process is often diffuse and retrograde embolization is a constant threat [20]. We think that axillary cannulation and flushing of the trifurcation graft may reduce particulate and air embolization while still providing an uncluttered operative field during the completion of the arch repair.
More specific to the current branched graft technique is the observation made during the earlier arch reconstructions using the patch graft method (HCA/SCP) that the cerebral vessels themselves are often free of severe atherosclerotic disease. Just a centimeter beyond the origins of these vessels from the arch, the severe atheromatous process usually dissipates; although occasionally atherosclerotic disease of the arch continues cephalad, vessels free of disease can almost always be reached by extending the sternotomy incision. We think that the construction of anastomoses in these smaller diameter vessels also contributes to our observed reduction in postoperative bleeding.
Although SCP is widely accepted [8] and appears in clinical studies to be the best method for cerebral protection when prolonged arrest of conventional CPB is required, the physiology of upper body perfusion with lower body ischemia has not been fully explored [22]. There is some clinical evidence to suggest that a prolonged total cerebral protection time (HCA plus SCP) is associated with poorer neurologic outcome, and it may be that SCP gradually leads to progressive cerebral vasoconstriction, restricting flow when perfusion is prolonged. It is not clear what constitutes an optimal flow rate, pressure, or volume for SCP or what temperature is ideal. These questions are currently being investigated in our laboratory and the answers should contribute to improving outcomes still further in this challenging group of patients.
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Conclusions |
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TopAbstractIntroductionPatients and methodsResultsCommentConclusionsDiscussionReferences |
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Discussion |
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TopAbstractIntroductionPatients and methodsResultsCommentConclusionsDiscussionReferences |
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DR SPIELVOGEL: Certainly. It actually tends to work exactly as you mentioned, that is that we try to maintain a cerebral perfusion pressure around 50 to 60 mmHg, but when you look at the volume, it tends to be around 10 cc/kg. The temperature after the period of circulatory arrest is allowed to drift upward. We don't maintain such cold perfusion. But the temperature eventually, by the time the arch is finished being reconstructed, is usually about 18 to 20 degrees Celsius. Once we finish the attachment of the branch graft to the arch graft, we actively rewarm. Does that answer your question, Dr Kazui?
DR KAZUI: Yes.
DR EDWARD PASCOE (Winnipeg, MB, Canada): We have followed Dr Griepp's lead in using the head vessel, or as we call it, the Griepp island technique, with comparable shortening of our circulatory arrest time and neurologic outcomes are equally gratifying. I applaud Dr Griepp for his contributions.
I have two brief questions. Are you still cooling to Dr Griepp's known standard of 12 degrees centigrade notwithstanding your shortening of circulating arrest time? Secondly, am I correct in assuming you prepare your trifurcation graft on the back table while you're cooling the patient?
DR SPIELVOGEL: As to our first question, the answer is yes, we still cool to the same degree. We think it provides the maximum protection to the patient's brain and if you look at the animal studies and the human studies, 30 minutes is about the limit of safe DHCA at that temperature, so we do cool the same amount.
In terms of fabricating the graft, we will do it after examining the brachiocephalic vessels before going on bypass. If, for instance, you have to do a Bentall first, we'll just have it made on the back table. If it's just an arch replacement, we'll do it while we're cooling. And actually we now have just received our first set of premanufactured grafts so we're going to be using those in the near future.
DR NICHOLAS T. KOUCHOUKOS, (St. Louis, MO): You grouped the mortality and I presume, the stroke rates together in the adverse outcomes category. Can you tell us about the stroke rates in the three groups and was there any difference between them?
DR SPIELVOGEL: I should have actually separated that out. There was a higher stroke rate in the first group as compared with the second and then the last group. Actually in the last group we only had 1 patient with severe neurologic injury postoperatively. We had 2 patients die.
DR KOUCHOUKOS: So what was the stroke rate for the last group, approximately?
DR SPIELVOGEL: The permanent stroke rate was, I think, 4%.
DR KOUCHOUKOS: Thank you. Since you are using axillary artery cannulation, once you establish the period of circulatory arrest it should be possible in some cases to clamp the brachiocephalic vessels and resume perfusion earlier and further shorten the duration of circulatory arrest. Have you done that? The interval of arrest could be brought down to 10 to 12 minutes and you could achieve perfusion of these vessels while you complete the anastomoses. Have you done that in any of your cases?
DR SPIELVOGEL: We haven't done that. I think part of the reason we have avoided that is, it comes down to the same reason why we don't believe in putting cannulas into the arteries. We feel that we can do the branch graft in 30 minutes and therefore avoid any manipulation of those vessels, whether it be clamps or cannulas: we complete the repair and then go on perfusion. But certainly in a young patient with no atherosclerotic disease that strategy is a great idea.
DR MARSHALL L. JACOBS (Philadelphia, PA): I would like to ask a final brief question. I think your presentation was very compelling and convincing with regard to reduction of the circulatory arrest time and the advantages associated with that. You did candidly state, though, that as you have more confidence in the technique, you've done more elective patients and patients with different types of arterial disease. Don't you think that some of the decreased ICU stay and decreased time on the ventilator and whatnot is related to having fewer acute dissections and a somewhat different patient population? When you've accomplished enough good science with the technique, you don't have to take credit for the shorter ICU time as well.
DR SPIELVOGEL: Fair enough.
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 D. Spielvogel, M. N. Mathur, and R. B. Griepp Aneurysms of the Aortic Arch Card. Surg. Adult, January 1, 2008; 3(2008): 1251 - 1276. [Full Text]
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G. J. Arnaoutakis, A. Bihorac, T. D. Martin, P. J. Hess Jr, C. T. Klodell, A. A. Ejaz, C. Garvan, C. G. Tribble, and T. M. Beaver RIFLE criteria for acute kidney injury in aortic arch surgery. J. Thorac. Cardiovasc. Surg., December 1, 2007; 134(6): 1554 - 1561. [Abstract] [Full Text] [PDF]
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K. Taniguchi, K. Toda, H. Hata, Y. Shudo, H. Matsue, T. Takahashi, and S. Kuki Elephant Trunk Anastomosis Proximal to Origin of Innominate Artery in Total Arch Replacement Ann. Thorac. Surg., November 1, 2007; 84(5): 1729 - 1734. [Abstract] [Full Text] [PDF]
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J. C. Halstead, C. Etz, D. M. Meier, N. Zhang, D. Spielvogel, D. Weisz, C. Bodian, and R. B. Griepp Perfusing the Cold Brain: Optimal Neuroprotection for Aortic Surgery Ann. Thorac. Surg., September 1, 2007; 84(3): 768 - 774. [Abstract] [Full Text] [PDF]
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 K.-M. Chiu, S.-J. Li, T.-Y. Lin, C.-Y. Chan, and S.-H. Chu Innominate Artery Cannulation for Aortic Surgery Asian Cardiovasc Thorac Ann, August 1, 2007; 15(4): 348 - 350. [Abstract] [Full Text] [PDF]
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D. Spielvogel, C. D. Etz, D. Silovitz, S. L. Lansman, and R. B. Griepp Aortic Arch Replacement With a Trifurcated Graft Ann. Thorac. Surg., February 1, 2007; 83(2): S791 - S795. [Abstract] [Full Text] [PDF]
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H. Sasaki, H. Ogino, H. Matsuda, K. Minatoya, M. Ando, and S. Kitamura Integrated Total Arch Replacement Using Selective Cerebral Perfusion: A 6-Year Experience Ann. Thorac. Surg., February 1, 2007; 83(2): S805 - S810. [Abstract] [Full Text] [PDF]
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K. Matsuura, H. Ogino, H. Matsuda, K. Minatoya, H. Sasaki, T. Yagihara, and S. Kitamura Limitations of EuroSCORE for Measurement of Risk-Stratified Mortality in Aortic Arch Surgery Using Selective Cerebral Perfusion: Is Advanced Age No Longer a Risk? Ann. Thorac. Surg., June 1, 2006; 81(6): 2084 - 2087. [Abstract] [Full Text] [PDF]
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 F. Jault, A. Rama, L. Lievre, N. Bonnet, P. Leprince, A. Pavie, and I. Gandjbakhch Chronic dissection of the ascending aorta: surgical results during a 20-year period (previous surgery excluded). Eur. J. Cardiothorac. Surg., June 1, 2006; 29(6): 1041 - 1045. [Abstract] [Full Text] [PDF]
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A. Della Corte, M. Scardone, G. Romano, C. Amarelli, A. Biondi, L. S. De Santo, M. De Feo, G. Nappi, and M. Cotrufo Aortic Arch Surgery: Thoracoabdominal Perfusion During Antegrade Cerebral Perfusion May Reduce Postoperative Morbidity Ann. Thorac. Surg., April 1, 2006; 81(4): 1358 - 1364. [Abstract] [Full Text] [PDF]
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K. Matsuura, H. Ogino, H. Matsuda, K. Minatoya, H. Sasaki, A. Kada, T. Yagihara, and S. Kitamura Prediction and Incidence of Atrial Fibrillation After Aortic Arch Repair Ann. Thorac. Surg., February 1, 2006; 81(2): 514 - 518. [Abstract] [Full Text] [PDF]
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K. Matsuura, H. Ogino, H. Matsuda, K. Minatoya, H. Sasaki, T. Yagihara, and S. Kitamura Surgical Outcome of Aortic Arch Repair for Patients With Takayasu Arteritis Ann. Thorac. Surg., January 1, 2006; 81(1): 178 - 182. [Abstract] [Full Text] [PDF]
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K. Matsuura, H. Ogino, H. Matsuda, K. Minatoya, H. Sasaki, T. Yagihara, and S. Kitamura Multivariate analysis of predictors of late stroke after total aortic arch repair Eur. J. Cardiothorac. Surg., September 1, 2005; 28(3): 473 - 477. [Abstract] [Full Text] [PDF]
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J. C. Halstead, D. Spielvogel, D. M. Meier, D. Weisz, C. Bodian, N. Zhang, and R. B. Griepp Optimal pH strategy for selective cerebral perfusion Eur. J. Cardiothorac. Surg., August 1, 2005; 28(2): 266 - 273. [Abstract] [Full Text] [PDF]
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D. Spielvogel, J. C. Halstead, M. Meier, I. Kadir, S. L. Lansman, R. Shahani, and R. B. Griepp Aortic Arch Replacement Using a Trifurcated Graft: Simple, Versatile, and Safe Ann. Thorac. Surg., July 1, 2005; 80(1): 90 - 95. [Abstract] [Full Text] [PDF]
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M. Yilmaz Total Aortic Arch Replacement Ann. Thorac. Surg., March 1, 2005; 79(3): 1097 - 1097. [Full Text] [PDF]
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A. L. Estrera, Z. Garami, C. C. Miller III, R. Sheinbaum, T. T.T. Huynh, E. E. Porat, B. S. Allen, and H. J. Safi Cerebral monitoring with transcranial Doppler ultrasonography improves neurologic outcome during repairs of acute type A aortic dissection J. Thorac. Cardiovasc. Surg., February 1, 2005; 129(2): 277 - 285. [Abstract] [Full Text] [PDF]
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