Moderate Hypothermic Circulatory Arrest (≥ 28°C) with Selective Antegrade Cerebral Perfusion for Total Arch Replacement with Frozen Elephant Trunk Technique

Abstract

Objectives The optimal hypothermic level during circulatory arrest in aortic arch surgery remains controversial, particularly in frozen elephant trunk (FET) procedures. We describe herein our experience for total arch replacement with FET technique under moderate systemic hypothermic circulatory arrest (≥ 28°C) during selective antegrade cerebral perfusion.

Methods Between January 2009 and January 2016, 38 consecutive patients underwent elective total arch replacement for various aortic arch pathologies with FET technique using the E-vita Open hybrid prosthesis (Jotec GmbH, Hechingen, Germany). Selective unilateral or bilateral cerebral perfusion under moderate systemic hypothermic circulatory arrest (28.7°C ± 0.5°C) was used in all patients. Minimally invasive total arch replacement with FET via partial upper sternotomy was performed in 15 patients (39%) and in the remaining 23 patients (61%) via full sternotomy. Mean late follow-up was 3 ± 2 years and was 98% complete. Clinical data were prospectively entered into our institutional database.

Results Cardiopulmonary bypass time accounted for 198 ± 58 minutes and the myocardial ischemic time 109 ± 29 minutes. Selective antegrade cerebral perfusion time was 55 ± 6 minutes. Lower body circulatory arrest time was 39 ± 11 minutes. Unilateral cerebral perfusion was performed in 31 patients (82%), and bilateral in 7 patients (18%). Intensive care unit stay was 4 ± 3 days. Thirty-day mortality was 5% (n = 2). Late survival at 3 years was 87 ± 3%. Two patients (5%) required reexploration for bleeding. Patients were discharged after a hospital length of stay of 7 ± 2 days. Postoperative permanent neurologic complication occurred in two patients (5%). Three patients (8%) experienced a transient neurologic disorder. New transient renal replacement therapy was necessary in three patients (8%). No spinal cord injury was noted.

Conclusions Our data suggest that moderate systemic hypothermic circulatory arrest (≥ 28°C) in combination with antegrade cerebral perfusion can safely be applied for total aortic arch replacement with FET and offers sufficient neurologic and visceral organ protection.

Keywords

aneurysm - aorta/aortic - perfusion - outcomes (includes mortality - morbidity)

• References

• 1 Kato M, Ohnishi K, Kaneko M. , et al. New graft-implanting method for thoracic aortic aneurysm or dissection with a stented graft. Circulation 1996; 94 (9, Suppl): II188-II193
• 2 Tian DH, Wan B, Di Eusanio M, Black D, Yan TD. A systematic review and meta-analysis on the safety and efficacy of the frozen elephant trunk technique in aortic arch surgery. Ann Cardiothorac Surg 2013; 2 (05) 581-591
• 3 Leontyev S, Tsagakis K, Pacini D. , et al. Impact of clinical factors and surgical techniques on early outcome of patients treated with frozen elephant trunk technique by using EVITA open stent-graft: results of a multicentre study. Eur J Cardiothorac Surg 2016; 49 (02) 660-666
• 4 Mestres CA, Tsagakis K, Pacini D. , et al; IEOR Registry Group. One-stage repair in complex multisegmental thoracic aneurysmal disease: results of a multicentre study. Eur J Cardiothorac Surg 2013; 44 (05) e325-e331
• 5 Urbanski PP, Lenos A, Bougioukakis P, Neophytou I, Zacher M, Diegeler A. Mild-to-moderate hypothermia in aortic arch surgery using circulatory arrest: a change of paradigm?. Eur J Cardiothorac Surg 2012; 41 (01) 185-191
• 6 Urbanski PP, Luehr M, Di Bartolomeo R. , et al. Multicentre analysis of current strategies and outcomes in open aortic arch surgery: heterogeneity is still an issue. Eur J Cardiothorac Surg 2016; 50 (02) 249-255
• 7 Tian DH, Wan B, Bannon PG. , et al. A meta-analysis of deep hypothermic circulatory arrest versus moderate hypothermic circulatory arrest with selective antegrade cerebral perfusion. Ann Cardiothorac Surg 2013; 2 (02) 148-158
• 8 Zierer A, El-Sayed Ahmad A, Papadopoulos N, Moritz A, Diegeler A, Urbanski PP. Selective antegrade cerebral perfusion and mild (28°C-30°C) systemic hypothermic circulatory arrest for aortic arch replacement: results from 1002 patients. J Thorac Cardiovasc Surg 2012; 144 (05) 1042-1049
• 9 Zierer A, Risteski P, El-Sayed Ahmad A, Moritz A, Diegeler A, Urbanski PP. The impact of unilateral versus bilateral antegrade cerebral perfusion on surgical outcomes after aortic arch replacement: a propensity-matched analysis. J Thorac Cardiovasc Surg 2014; 147 (04) 1212-1217 , discussion 1217–1218
• 10 Zierer A, El-Sayed Ahmad A, Papadopoulos N. , et al. Fifteen years of surgery for acute type A aortic dissection in moderate-to-mild systemic hypothermia. Eur J Cardiothorac Surg 2017; 51 (01) 97-103
• 11 Zierer A, Detho F, Dzemali O, Aybek T, Moritz A, Bakhtiary F. Antegrade cerebral perfusion with mild hypothermia for aortic arch replacement: single-center experience in 245 consecutive patients. Ann Thorac Surg 2011; 91 (06) 1868-1873
• 12 El-Sayed Ahmad A, Risteski P, Papadopoulos N, Radwan M, Moritz A, Zierer A. Minimally invasive approach for aortic arch surgery employing the frozen elephant trunk technique. Eur J Cardiothorac Surg 2016; 50 (01) 140-144
• 13 El-Sayed Ahmad A, Papadopoulos N, Risteski P, Moritz A, Zierer A. The standardized concept of moderate-to-mild (≥28°C) systemic hypothermia during selective antegrade cerebral perfusion for all-comers in aortic arch surgery: single-center experience in 587 consecutive patients over a 15-year period. Ann Thorac Surg 2017; 104 (01) 49-55
• 14 El-Sayed Ahmad A, Papadopoulos N, Risteski P. , et al. Is more than one hour of selective antegrade cerebral perfusion in moderate-to-mild systemic hypothermic circulatory arrest for surgery of acute type A aortic dissection safe?. Thorac Cardiovasc Surg 2017; DOI: 10.1055/s-0037-1604451.
• 15 Karck M, Kamiya H. Progress of the treatment for extended aortic aneurysms; is the frozen elephant trunk technique the next standard in the treatment of complex aortic disease including the arch?. Eur J Cardiothorac Surg 2008; 33 (06) 1007-1013
• 16 Kourliouros A, Vecht J, Kakouros N. , et al. Frozen elephant trunk as an effective alternative to open and hybrid two-stage procedures for complex aortic disease. Hellenic J Cardiol 2011; 52 (04) 337-344
• 17 Leontyev S, Borger MA, Etz CD. , et al. Experience with the conventional and frozen elephant trunk techniques: a single-centre study. Eur J Cardiothorac Surg 2013; 44 (06) 1076-1082 , discussion 10831
• 18 Di Eusanio M, Borger M, Petridis FD. , et al. Conventional versus frozen elephant trunk surgery for extensive disease of the thoracic aorta. J Cardiovasc Med (Hagerstown) 2014; 15 (11) 803-809
• 19 Shrestha M, Bachet J, Bavaria J. , et al. Current status and recommendations for use of the frozen elephant trunk technique: a position paper by the Vascular Domain of EACTS. Eur J Cardiothorac Surg 2015; 47 (05) 759-769
• 20 Jakob H, Tsagakis K, Pacini D. , et al. The International E-vita Open Registry: data sets of 274 patients. J Cardiovasc Surg (Torino) 2011; 52 (05) 717-723
• 21 Tokuda Y, Miyata H, Motomura N, Oshima H, Usui A, Takamoto S. ; Japan Adult Cardiovascular Database Organization. Brain protection during ascending aortic repair for Stanford type A acute aortic dissection surgery. Nationwide analysis in Japan. Circ J 2014; 78 (10) 2431-2438
• 22 Di Bartolomeo R, Pacini D, Savini C. , et al. Complex thoracic aortic disease: single-stage procedure with the frozen elephant trunk technique. J Thorac Cardiovasc Surg 2010; 140 (6, Suppl): S81-S85 , discussion S86–S91
• 23 Di Eusanio M, Pantaleo A, Murana G. , et al. Frozen elephant trunk surgery-the Bologna's experience. Ann Cardiothorac Surg 2013; 2 (05) 597-605
• 24 Leontyev S, Misfeld M, Daviewala P. , et al. Early- and medium-term results after aortic arch replacement with frozen elephant trunk techniques-a single center study. Ann Cardiothorac Surg 2013; 2 (05) 606-611
• 25 Ma M, Liu L, Feng X. , et al. Moderate hypothermic circulatory arrest with antegrade cerebral perfusion for rapid total arch replacement in acute type A aortic dissection. Thorac Cardiovasc Surg 2016; 64 (02) 124-132
• 26 Di Eusanio M, Schepens MA, Morshuis WJ, Di Bartolomeo R, Pierangeli A, Dossche KM. Antegrade selective cerebral perfusion during operations on the thoracic aorta: factors influencing survival and neurologic outcome in 413 patients. J Thorac Cardiovasc Surg 2002; 124 (06) 1080-1086
• 27 Leshnower BG, Kilgo PD, Chen EP. Total arch replacement using moderate hypothermic circulatory arrest and unilateral selective antegrade cerebral perfusion. J Thorac Cardiovasc Surg 2014; 147 (05) 1488-1492
• 28 Kamiya H, Hagl C, Kropivnitskaya I. , et al. The safety of moderate hypothermic lower body circulatory arrest with selective cerebral perfusion: a propensity score analysis. J Thorac Cardiovasc Surg 2007; 133 (02) 501-509
• 29 Pacini D, Pantaleo A, Di Marco L. , et al. Visceral organ protection in aortic arch surgery: safety of moderate hypothermia. Eur J Cardiothorac Surg 2014; 46 (03) 438-443