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Aortic arch replacement with a trifurcated graft
David Spielvogel1, Christian D Etz, Daniel Silovitz
1Section of Cardiothoracic Surgery, New York College of Medicine, Westchester Medical Center, Valhalla 10595, USA. spielvogeld@wcmc.com
Insights
A trifurcated arch graft with hypothermic circulatory arrest (HCA) and selective antegrade cerebral perfusion (SCP) is a safe and versatile technique for aortic arch aneurysm repair. This method demonstrated an 8.7% adverse outcome rate in 150 patients.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Vascular Surgery
Background:
- Aortic arch aneurysms pose significant surgical challenges.
- Hypothermic circulatory arrest (HCA) and selective antegrade cerebral perfusion (SCP) are critical for brain protection during aortic arch surgery.
Purpose of the Study:
- To evaluate the efficacy and safety of using a trifurcated arch graft combined with HCA and SCP for aortic arch replacement.
- To analyze outcomes in patients undergoing complex aortic arch reconstructions.
Main Methods:
- A retrospective review of 150 consecutive patients undergoing aortic arch replacement with a trifurcated graft and HCA/SCP.
- Axillary artery cannulation, HCA with SCP via the trifurcated graft, and detailed analysis of patient demographics, comorbidities, and surgical procedures.
- Use of an elephant trunk in 144 patients with varying distal extensions.
Main Results:
- An overall adverse outcome rate of 8.7% (13 of 150 patients), including 7 hospital deaths and 6 permanent strokes.
- Low rates of temporary neurologic dysfunction (7 patients) and transient renal failure requiring dialysis (9 patients).
Conclusions:
- The trifurcated arch graft in conjunction with HCA and SCP is a safe and versatile approach for aortic arch aneurysm repair.
- This technique facilitates complex aortic arch reconstructions with acceptable morbidity and mortality.
Background:
The purpose of this study was to review the results of aortic arch replacement using a trifurcated arch graft in conjunction with hypothermic circulatory arrest (HCA) and selective antegrade cerebral perfusion (SCP).
Methods:
One hundred fifty consecutive patients (91 male; mean age, 63 +/- 14 years; range, 20 to 87) had aortic arch replacement using a trifurcated arch graft and HCA/SCP from September 1999 to December 2005. The axillary artery was used for cannulation; a trifurcated graft was sewn to the arch vessels during a short interval of HCA; SCP was utilized through the trifurcation graft during the proximal and distal arch repair, and then the trifurcation graft was sewn to the arch graft. Fifty-five patients had chronic dissection; 48 had atherosclerotic and 29 had degenerative aneurysms; 74 had undergone previous cardiac surgery. Isolated arch reconstruction was undertaken in 38 patients: concomitant procedures included ascending aortic replacement in 74; ascending aorta and root replacement in 21; descending replacement in 4, and coronary artery bypass grafting in 36. An elephant trunk was used in 144, but distal to the left subclavian artery in only 87; in 34, it was distal to the left carotid, in 9, it was between the brachiocephalic and left carotid, and in 18, it was proximal to all arch branches. Mean HCA duration was 31.1 +/- 6.5 minutes; SCP lasted 66.6 +/- 21.0 minutes, at a mean temperature of 15.8 +/- 2.1 degrees C.
Results:
Adverse outcome occurred in 13 of 150 patients (8.7%): there were 7 hospital deaths and 6 permanent strokes. Temporary neurologic dysfunction was seen in only 7 patients, and renal failure was transient in 9 patients requiring dialysis.
Conclusions:
The use of a trifurcated arch graft with HCA and SCP is a safe and versatile technique for repair of arch aneurysms.
