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Improving results of open arch replacement.

Thoralf M Sundt¹, Thomas A Orszulak, David J Cook

¹Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota 55905, USA. sundt.thoralf@mayo.edu

The Annals of Thoracic Surgery

|August 30, 2008

Summary

Open aortic arch replacement shows improved outcomes with modern cerebral protection techniques. Endovascular therapies should be compared against these contemporary surgical results for accurate assessment.

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Area of Science:

Cardiovascular Surgery
Thoracic Surgery
Vascular Surgery

Background:

The rise of endovascular techniques for aortic arch reconstruction necessitates a clear understanding of current open surgery outcomes.
Conventional open arch surgery outcomes provide a crucial benchmark for evaluating emerging endovascular therapies.

Purpose of the Study:

To evaluate the contemporary outcomes of conventional open aortic arch replacement surgery.
To assess the impact of advanced cerebral protection strategies on surgical results.

Main Methods:

A retrospective review of 347 patients undergoing aortic arch reconstruction between 1993 and 2007 was conducted.
Perioperative (30-day) outcomes were analyzed using The Society of Thoracic Surgeons database.
The study compared outcomes based on different cerebral protection modalities: profound hypothermia and circulatory arrest, retrograde cerebral perfusion, and selective antegrade cerebral perfusion.

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Main Results:

Overall mortality was 8.9% (6.0% for elective procedures), and stroke rate was 8.4% (6.9% for elective procedures).
Mortality for total arch replacement significantly decreased with the introduction of selective antegrade cerebral perfusion (6.0% overall, 2.7% elective) compared to profound hypothermia and circulatory arrest (34.6% overall, 30.0% elective).
While stroke rates showed a trend towards improvement with newer techniques, the difference was not statistically significant (p=0.18 overall, p=0.46 elective).

Conclusions:

Open aortic arch replacement, especially under elective conditions, can be performed with low operative mortality and morbidity.
The use of adjunctive cerebral protection measures, particularly selective antegrade cerebral perfusion, has markedly improved outcomes.
Contemporary surgical results should serve as the standard against which the efficacy of endovascular aortic arch repair techniques is measured.