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a Division of Cardiovascular Surgery, Mayo Clinic Rochester, Rochester, Minnesota
b Division of Anesthesiology, Mayo Clinic Rochester, Rochester, Minnesota
Accepted for publication May 5, 2008.
* Address correspondence to Dr Sundt, Division of Cardiovascular Surgery, Mayo Clinic, 200 First St, SW, Rochester, MN 55905 (Email: sundt.thoralf{at}mayo.edu).
Presented at the Forty-fourth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28–30, 2008.
| Dr Sundt discloses that he has a financial relationship with Boston Scientific.
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Abstract |
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 Top Abstract IntroductionMaterial and MethodsResultsCommentDiscussionAcknowledgmentsReferences |
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Methods: Cases of arch reconstruction were identified by search of the computerized cardiovascular surgical database. Perioperative (30-day) outcomes as per The Society of Thoracic Surgeons database were evaluated.
Results: Between January 1, 1993, and June 30, 2007, 347 patients (195 male, 152 female; median age, 69 years; range, 21 to 88 years) underwent aortic arch replacement. Procedures were elective in 232 cases. Total arch replacement was performed in 95, including 15 with concomitant replacement of the descending thoracic aorta by means of bilateral thoracosternotomy. Modalities adjunctive to profound hypothermia and circulatory arrest for cerebral protection have been introduced, including retrograde cerebral perfusion and, more recently, selective antegrade cerebral perfusion. The overall mortality rate was 8.9% (elective procedures, 6.0%) and stroke rate was 8.4% (elective procedures, 6.9%). The mortality rate for total arch replacement has declined with adjuncts overall from 34.6% (9 of 26) with profound hypothermia and circulatory arrest to 21.1% (4 of 19) with retrograde cerebral perfusion and to 6.0% (3 of 50) with selective antegrade cerebral perfusion (p < 0.01), and for elective cases from 30.0% (6 of 20) with profound hypothermia and circulatory arrest to 14.3% (2 of 14) with retrograde cerebral perfusion, and 2.7% (1 of 37) with selective antegrade cerebral perfusion (p < 0.01). The corresponding stroke rates were 19.2% (5 of 26) with profound hypothermia and circulatory arrest, 5.3% (1 of 19) with retrograde cerebral perfusion, and 6.0% (3 of 50) with selective antegrade cerebral perfusion (p = 0.18) overall and 15.0% (3 of 20) with profound hypothermia and circulatory arrest, 7.1% (1 of 14) with retrograde cerebral perfusion, and 5.4% (2 of 37) with selective antegrade cerebral perfusion (p = 0.46) for elective cases.
Conclusions: Currently, open aortic arch replacement can be accomplished under elective circumstances with low operative mortality, particularly with adjunctive measures for cerebral protection. The results of endovascular therapies should be measured against contemporary surgical series.
Aortic arch replacement is a technically challenging procedure, and one that has been associated in the past with significant mortality and morbidity. Accordingly, as success has been achieved with endovascular approaches to descending thoracic aortic aneurysmal disease, attention has turned to the application of these technologies to diseases of the aortic arch. These include debranching procedures [1] and use of fenestrated or branched endovascular stent grafts [2]. To evaluate the appropriate application of these less invasive technologies, however, one needs a clear understanding of the results that can be expected from open approaches using current techniques.
Significant advances in open arch surgery have been made during the past several decades. Since the earliest series of arch replacements reported by Griepp and colleagues [3], profound hypothermia and circulatory arrest (PHCA) has served our patients remarkably well and remains the cornerstone for protection of the central nervous system and other end organs. Adjunctive techniques have been introduced with the aim of addressing the shortcomings of PHCA [4], as well as the need for conduct of more complex procedures to correct extensive aortic diseases [5]. Retrograde cerebral perfusion (RCP) was introduced with promising early results [6], and continues to be embraced by many [7–9]. Controversy has built within the cardiac surgical community, however, whether substantial cerebral flow is provided by RCP as evaluated in the laboratory [10], or reflected in substantive clinical impact [11]. More recently, Kazui and associates [12] and Bachet and coworkers [13] have championed selective antegrade perfusion (SACP) with excellent outcomes in their hands and those of others [14, 15]. Some surgeons have been willing to surrender the protective affects of profound hypothermia in favor of only moderate systemic cooling in the interest of reducing perfusion times and coagulopathy associated with prolonged cardiopulmonary bypass [14]. In addition, use of the right axillary artery for arterial inflow has been introduced and also widely accepted [16, 17]. The two techniques are complementary, as axillary perfusion makes SACP quite straightforward technically. The summary result has been a remarkable reduction in mortality and morbidity for arch replacement [18].
With a view toward evaluating our current results with open aortic arch repair as a foundation for better determining which patients should receive traditional reconstruction versus stent graft repair, we reviewed our recent experience with arch replacement, focusing principally on the end points of mortality and stroke. During that interval our group has used PHCA alone, RCP, and SACP. Accordingly, the impact of these cerebral protective strategies as well as that of axillary inflow on these outcomes was examined.
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Material and Methods |
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As of the time of this study, cases had been abstracted up to June 30, 2007. Patient demographics and comorbidities were derived from The Society of Thoracic Surgeons database. Thirty-day outcomes including mortality and stroke were the primary outcomes of interest. Operative notes were screened by one of the authors (T.M.S.) to assure consistency of recording circulatory arrest episodes and technical factors. Both cerebral circulatory arrest and corporeal circulatory arrest were considered in statistical analysis.
Surgical Technique
There is no standardized approach to thoracic aortic disease within our institution. These procedures were performed by 12 surgeons, although greater than 90% were performed by the authors and one previous member of the division (K.J. Zehr). There are some general statements that can be made, however, which are applicable in most instances.
The site of arterial cannulation is determined at the discretion of the operating surgeon. In general, axillary artery inflow is currently used in the repair of degenerative aneurysms in the interest of reducing the risk of atheroembolism from a central cannulation site. Axillary inflow provides for flow directed away from the cerebral circulation, particularly across anastomoses, at all phases of the operation. Axillary inflow is also preferred when total arch replacement is anticipated as it simplifies the institution of SACP. We routinely conduct axillary perfusion using an 8-mm sidearm graft rather than through direct arterial cannulation as this optimizes flows and reduces the risks of cannulation-induced vascular complications. Consonant with our institutional posture toward simplifying procedures whenever possible, however, we use central cannulation in the setting of connective tissue disease disorders such as Marfan's or in the setting of bicuspid aortic valve when hemiarch replacement is anticipated, as there is less concern regarding the atherosclerotic burden of the ascending aorta itself. This obviates the need for axillary dissection with the concomitant risks of brachial plexus injury or vascular complications, both of which are uncommon but can be catastrophic.
The cornerstone of cerebral protection remains profound hypothermia. Cardiopulmonary bypass is routinely instituted at 2.2 to 2.5 L · min–1 · m–2. Cooling is conducted for a minimum of 30 minutes with a maximum temperature gradient of 10°C between the water entering the heat exchanger and the patient's nasopharyngeal temperature. Cooling is generally to a nasopharyngeal temperature of 16° to 18°C or an isoelectric processed electroencephalogram, and bladder temperature less than 23°C. More recently, particularly with the introduction of SACP, we have been willing to accept somewhat higher core temperatures (25°C) when hemiarch replacement is planned, particularly among patients with high body mass, although thus far we have been reluctant to reduce the minimum cooling time. During systemic cooling we use the pH-stat strategy for acid-base management until circulatory arrest. Our target hematocrit is 21% to 27% during cooling between 37° and 32°C, and 18% to 23% before circulatory arrest. During the arrest episode the head is packed in ice to prevent ambient warming. Once rewarming has begun, alpha-stat management is initiated with a target hematocrit of 18% to 21% below 25°C and 24% to 30% above 32°C. During rewarming the maximum temperature gradient is again 10°C, and arterial inflow temperature does not exceed 37.5°C.
Application of adjunctive cerebral protection measures such as RCP or SACP is at the discretion of the operating surgeon, although there is a general preference for the use of such adjuncts principally in the setting of total arch replacement as compared with hemiarch replacements. Retrograde cerebral perfusion was accomplished either by reversing flow in a venous return cannula placed in the superior vena cava or through a retrograde cardioplegia cannula placed in the superior vena cava. This technique has been essentially abandoned in our current practice, however, in favor of SACP.
Selective antegrade perfusion is most often instituted by means of right axillary artery inflow as this obviates the need to cannulate the brachiocephalic trunk, which may clutter the operative field and introduces the possibility of vascular injury or atheroembolism with instrumentation. We have not perfused the left carotid artery routinely, as we believe our primary protection remains hypothermia and we have regarded SACP as an adjunct rather than substitute for the same. It is also our practice to reconstruct the arch vessels first, using either a trifurcated graft or a branched arch graft, such that once these anastomoses have been performed, antegrade flow in the left carotid and left subclavian is restored through the common lumen. During branch reconstruction or hemiarch replacement with SACP, the stumps of all three vessels are controlled with vascular clamps or, in selected cases in which stump pressures are to be measured, with balloon catheters. During SACP the perfusate is maintained at 13°C and flow through the axillary artery is maintained between 10 and 15 mL · kg–1 · min–1 based on current recommendations from the literature. Among those in whom prolonged episodes of SACP are anticipated, the flow rate has most recently been guided by pressures measured in the ipsilateral brachiocephalic artery and left carotid stumps with a goal to maintain an ipsilateral mean arterial pressure between 50 and 60 mm Hg and contralateral mean arterial pressure greater than 30 mm Hg. In 7 of the most recent total arch cases, brachiocephalic and left carotid stump pressures were measured using retrograde cardioplegia balloon catheters and recorded at 5, 10, and 15 mL · kg–1 · min–1. We do not routinely use cerebral oximetry devices as the degree to which they meaningfully measure intracranial oxygen saturation is unproven in our opinion.
Statistical Methods
Descriptive statistics for categorical variables are reported as frequency and percentage whereas continuous variables are reported as mean (standard deviation) or median (range) as appropriate. Categorical variables were compared between perfusion groups using 
2 test and continuous variables were compared using analysis of variance or Kruskal-Wallis rank-sum test as appropriate. Logistic regression models were used to find the univariate and multivariate predictors of operative mortality and postoperative stroke. The multivariable model considered univariately significant variables (p < 0.05) with model selection using the stepwise method. All statistical tests were two-sided with the alpha level set at 0.05 for statistical significance.
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Results |
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TopAbstractIntroductionMaterial and MethodsResultsCommentDiscussionAcknowledgmentsReferences |
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Operative outcomes are shown in Table 3. When considered according to perfusion strategy, the mortality rate overall was similar whether PHCA or SACP was used; however, it was significantly higher with RCP. The difference between RCP and PHCA groups likely in part reflects the slight overrepresentation of acute dissections in the former group (Table 1), although the same trend toward higher mortality was present among elective cases as well. Total arch replacement was also more commonly performed in the RCP than PHCA group (36% versus 12%) as shown in Table 2. In contrast, the similarity in mortality rate between SACP and PHCA is particularly notable in this regard as total arch replacement was performed in 68% of SACP patients (Table 2). There was a slight trend overall for a somewhat lower stroke rate with SACP (Table 3), although it must be acknowledged that there is always the possibility that stroke rate is underestimated owing to unrecognized strokes among those patients with perioperative mortalities who never awakened. Reoperation for bleeding was more common in the SACP group, perhaps because of the higher frequency of total arch replacement.
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Because procedure types differed among perfusion strategy groups with hemiarch replacement most often conducted in our practice with PHCA alone, we focused on total arch replacement as one would anticipate arrest times to be longest here and the impact of perfusion strategy to matter most (Table 4). Overall, operative mortality was statistically significantly lower when SACP was used despite small numbers of cases performed. The difference in stroke was not statistically significant, although there was a trend for lower stroke rates with adjuncts. Among elective cases alone, again SACP was associated with lower mortality rate (2.7% versus 30.0% for PHCA and 14.4% for RCP; p < 0.01) Again, numbers are small and statistical significance was not achieved; however, the stroke rate also trended lower with SACP (5.4%) versus PHCA (15.0%) and RCP (7.1%). Under emergent circumstances the mortality rate with SACP was high (15.4%), but lower than for PHCA (50%) or RCP (40%).
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Predictors of operative mortality by univariate analysis (Table 5) included emergent status (p = 0.01), total arch replacement (p < 0.01 versus hemiarch replacement), and perfusion time as well as arrest time. Use of RCP was a significant predictor of death versus PHCA. By multivariate analysis, emergent status, total arch versus hemiarch, and perfusion time remained significant predictors. For stroke, only age was predictive by univariate analysis. Notably, there were no strokes among patients with a prior history of cerebrovascular events.
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Comment |
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TopAbstractIntroductionMaterial and MethodsResultsCommentDiscussionAcknowledgmentsReferences |
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Antegrade perfusion of the cerebral vasculature during arch replacement is not a novel concept, having been used by the pioneers of arch surgery [19, 20]. Indeed, given the burgeoning interest in SACP with only mild hypothermic systemic perfusion and cannulation of individual brachiocephalic vessels, it is humbling to recognize that PHCA was heralded as an advance principally because it simplified the operation, freeing the operative field from multiple cannulas [3]. This advantage to PHCA remains as true today as before, and is the principal advantage cited by those who continue to advocate it as the preferred method for cerebral protection. The Yale group argues cogently that in cases in which the arrest episode can be expected to be brief and for those surgeons who perform arch surgery infrequently, PHCA is the simplest and most straightforward approach [21]. The vast majority of acute aortic dissections treated in the United States with hemiarch replacement likely fall into this group, and we would agree that in this setting simplicity is of particular value. We also note that we are reluctant to perform total arch replacement in the setting of acute dissection, a position supported by the data presented here.
Despite the advantage of technical simplicity for the surgeon, the limitations of PCHA alone as a strategy for cerebral protection have become increasingly apparent as operative mortality has declined and attention has turned to preservation of neurologic function. In the aforementioned series from Yale, when arrest episodes exceed 40 minutes, the stroke rate exceeded 13%. Arrest times longer than 40 minutes also approached statistical significance (p = 0.06) for mortality (odds raio, 1.56) [21]. The incidence of transient neurologic dysfunction, itself a marker for subtle neurologic damage, has also been shown to correlate with duration of circulatory arrest [4]. Furthermore, surgeons are increasingly challenged to repair more complex diseases which demand longer periods of corporeal arrest [5]. In this regard SACP has emerged as an enabling technology; the recent literature is replete with reports, some quite large, of remarkably low operative mortality rates and stroke rates despite complex aortic arch reconstructions [15]. Our practice has been influenced by these trends, particularly since the popularization of axillary artery inflow [16, 22], which obviates the need for multiple cannulas in the operative field.
We have thus far continued to cool systemically for a minimum of 30 minutes and to a target temperature of 18° to 20°C nasopharyngeal despite the suggestion by others that mild hypothermia will suffice [23]. In our experience the oft-mentioned adverse effects of profound hypothermia have been less troublesome than others have suggested, with the principal disadvantage being the inconvenience of prolonged rewarming time. Accordingly we have treated SACP as an adjunct rather than a substitute for what has proven to be quite satisfactory neurologic protection. We have been reluctant to reduce cooling out of concern for the adequacy of contralateral cerebral perfusion given our current technique providing only unilateral inflow. The validity of this concern is born out by the clinical results reported with this approach in 1999 by Wozniak and colleagues [23]. They reported 2 cases of temporary left-sided hemiparesis among 21 patients treated with moderate hypothermic perfusion (28°C) and unilateral perfusion. Although the authors thought this was an adequate outcome, the rate of neurologic event (9.5%) is twice what we have observed with SACP and profound hypothermia. Our unease about unilateral perfusion stimulated us to measure left carotid stump pressures, and indeed the results support those concerns. The obvious alternative of simultaneous left carotid cannulation and perfusion remains an option as well, although this again clutters the operative field. These same measurements also demonstrated concerning variation between arterial inflow rates and stump pressures. Unfortunately there is a paucity of data in the literature to support recommended flow rates during SACP. Even more uncertainty arises out of the loss of cerebral autoregulation at low temperatures, making the risks of hyperperfusion as real as those of hypoperfusion. These findings support routine monitoring of cerebrovascular pressures as well as flow rates.
The current study has limitations shared by all retrospective studies. Although it would be optimal to test strategies prospectively in a randomized manner, arch replacement in our institution remains relatively uncommon and such a study would be impractical. Although observational studies such as this may be subject to selection or treatment bias, if anything, one might anticipate SACP to be applied in higher risk cases. This should bias the results against SACP. In addition, other elements in our perioperative management strategy have changed with time. Finally, the study itself is based on the experience of a number of surgeons, which may be perceived as a strength or weakness. Although this introduces some inconsistency in approach, it makes it perhaps somewhat more representative of the generalizability of the approach.
In summary, our current practice is to use axillary perfusion when undertaking repair of atherosclerotic aneurysms. Selective antegrade perfusion is used when total arch replacement is planned or a prolonged episode of circulatory arrest is otherwise anticipated. The operative risk is low with PHCA alone when circulatory arrest times are brief, as may be anticipated with hemiarch replacement. If in doubt, however, axillary perfusion permits rapid change in strategy to use SACP without complicating matters excessively. We have concerns regarding the adequacy of unilateral SACP alone as a neuroprotective strategy in the setting of only moderate hypothermia.
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Discussion |
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TopAbstractIntroductionMaterial and MethodsResultsCommentDiscussionAcknowledgmentsReferences |
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DR SUNDT: I don't think I've looked at it that way. So you're asking whether the distribution of acute dissections was higher in the RCP group or not. I'll have to look back at that to be honest with you. Well, yes, I guess I didn't obsess over it too much because we have pretty well abandoned RCP. It's of historical interest in my book. But I'll look back and look at that. It's a good suggestion.
DR THOMAS G. GLEASON (Pittsburgh, PA): Most groups come to the same conclusion that your group has, that clearly antegrade cerebral perfusion offers a lower stroke rate and a better survival. The question you raise about its safety as [we] push [to] doing these cases at warmer temperatures (ie, moderate hypothermia) is quite a relevant one. One of my specific concerns, even with bilateral carotid perfusion, is as we warm the temperature, are we putting the spinal cord at greater risk? What are your thoughts about spinal cord protection and its adequacy with the use of antegrade cerebral perfusion and only moderate hypothermia?
DR SUNDT: Yes, I agree with your concerns. And I'm a bit of a "little old lady" about those things. It is taking me a while to get the confidence to warm the perfusate up. If it's a complex repair, something that we're doing through a clamshell or something like that, I like to be cold. That's the way Dr Kouchoukos taught me to work and I feel comfortable that way.
I think the patients where I'm tempted to go warmer and warmer are the hemiarch replacements, when you really have to ask yourself, "Why did I cool so long when all I'm doing is a hemiarch replacement with a very brief arrest episode?" And so those are the ones that I'm going warmer and warmer with. But I worry about the left side of the brain and especially subtle changes on the left side that may not manifest as a stroke but sort of a unilateral version of transient neurologic dysfunction. That can't be good for your head.
DR T. BRUCE FERGUSON (Greenville, NC): So, Lord Kelvin, please, how warm is warm?
DR SUNDT: How warm is warm? Well, I am not sure, but I think I know how cold "cold" is. And cold is 18° nasopharyngeal, so that's the target that I cool to. And I was taught to cool for at least 30 minutes. And I just am having a hard time backing off of that.
That's too warm or too cold?
DR FERGUSON: That's 291.15 in Kelvin's scale.
DR JEFFREY H. SHUHAIBER (Cambridge, UK): As you are well aware, there is a school of thought that you could use retrograde cerebral perfusion right at the beginning and at the end of your arch repair. What do you think of that procedure? Doctor Sundt, I enjoyed your presentation.
DR SUNDT: To flush debris?
DR SHUHAIBER: Yes. In combination with selective antegrade cerebral perfusion.
DR SUNDT: I think that that's a reasonable approach, but if you do selective antegrade from the axillary, you get the same effect. It blows blood and debris away from the head vessels. So that's another reason why I actually like the selective antegrade.
DR ANTONIO LAUDITO (Turin, Italy): Regarding the surgical strategy for the open hemiarch anastomosis: would you be comfortable to keep the temperature not lower than 26°C perfusing the left, the right carotid and having a catheter going down in the descending aorta, like a simple Foley, that will perfuse the lower part of the body?
DR SUNDT: There are others who feel that way, who are interested in perfusing both carotids and the descending with separate cannulae. Actually, that is why I put up that quote from Dr Ecker. Isn't it remarkable to remember our history, our surgical history, our surgical heritage as we look at what we do today. The approach with multiple perfusion catheters is the way Dr Cooley and Dr Debakey did the first aneurysms! And when Dr Griepp introduced profound hypothermia, it was welcomed as a way to simplify the operation. So to some degree we're going backwards repeating the past. In the end I think you have to balance what's optimal for you and for your patient's circumstances. For me, a hemiarch replacement with a lot of catheters in the lumen is a pain in the neck. So if you're going to be able to do the anastomosis relatively quickly, it's probably simpler to just cool a bit more and do it without any kind of perfusion. Especially if the patient is not too big and rewarming will not take too long. But there are lots of ways to skin a cat.
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 WRITING GROUP MEMBERS, L. F. Hiratzka, G. L. Bakris, J. A. Beckman, R. M. Bersin, V. F. Carr, D. E. Casey Jr, K. A. Eagle, L. K. Hermann, E. M. Isselbacher, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine Circulation, April 6, 2010; 121(13): e266 - e369. [Full Text] [PDF]
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G. C. Hughes, M. A. Daneshmand, K. R. Balsara, H. A. Achneck, B. Sileshi, S. M. Lee, and R. L. McCann "Hybrid" Repair of Aneurysms of the Transverse Aortic Arch: Midterm Results Ann. Thorac. Surg., December 1, 2009; 88(6): 1882 - 1888. [Abstract] [Full Text] [PDF]
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) by circulatory arrest time for profound hypothermia and circulatory arrest (A), retrograde cerebral perfusion (B), and selective antegrade cerebral perfusion (C) patients are shown. The risk of operative mortality and stroke rise with arrest time when profound hypothermia and circulatory arrest alone is used. This effect is less apparent when retrograde cerebral perfusion is used. Selective antegrade cerebral perfusion appears to neutralize the impact of arrest time on mortality and stroke.