Single Carotid Cannulation for Selective Antegrade Cerebral Perfusion: A Safe and Effective Tailored Approach in Moderate-Risk Patients undergoing Contemporary Minimally Invasive Primary Aortic Arch Repair

Objectives: We reviewed the safety and efficacy of our approach to contemporary aortic arch repair using single right common carotid cannulation technique with selective antegrade cerebral perfusion (sACP) in patients undergoing minimally invasive arch surgeries.

Methods: From June 2012 to February 2019, elective, emergent arch repairs were performed on 90 patients (n = 70 underwent moderate hypothermia circulatory arrest [HCA] + sACP [with HCA group] and n = 20 underwent no HCA [without group]). Median age of patients was 68 years (IQR, 39–83 years) and 79% were men. Hypertension was present in 69% of patients and 32% presented with NYHA III–IV. At the time of presentation, 13% were in reduced LVEF (< 50%). Moderate-severe aortic insufficiency was documented in 24% of patients and 47% with combined aortic stenosis–aortic insufficiency. Patients with endocarditis and acute aortic dissection were excluded. Euroscore was 5 ± 4.3 (sACP 5 ± 4.1 vs. no HCA 5 ± 5.2, p = 0.93). Longer CPB time was found for those who had HCA (median: 136 minutes [IQR: 74–263] vs. 116 minutes [IQR 83–218]) without (p < 0.05) but no difference observed in median aortic cross-clamp time (84 minutes with vs. 71 minutes without; p = 0.29). The median total circulatory arrest time was 12 minutes (IQR: 7–35).

Results: There are no differences associated with the use of moderate HCA + sACP in rates of overall mortality within 30 days (2% with and 0% without) or stroke (3% and 0% without). Prolonged ventilation was similar (10% for both groups). Median length of intensive care unit and hospital stays were not different between groups: 1 and 11 days for both groups, respectively. Overall levels of creatinine (p = 0.280) and GFR (p = 0.525) remained stable and decreased levels of alkaline phosphatase (p = 0.000), GOT (p = 0.000), and GPT (p = 0.000) were observed in HCA group over 48 hours postoperative. At a median follow-up of 1.5 and 1.6 years, respectively, freedom from stroke (FS) and overall survival (OS) rates were similar at 1, 2, 3, 4, and 5 years (FS: with 96, 96, 96, 96, and 96% vs. without 94, 94, 94, 94, and 94% and OS: with 98, 95, 95, 95, and 95% vs. without 100, 100, 100, 100, and 50%; p = 0.679 and p = 0.936), respectively.

Conclusion: Moderate HCA with sACP via single carotid cannulation resulted in equivalent rates of freedom from postoperative stroke and midterm survival for moderate-risk patients undergoing minimally invasive aortic arch repairs with a benefit of low incidence rates of renal and hepatic failure and perioperative complications.