Branch-first aortic arch replacement with no circulatory arrest or deep hypothermia

For aortic arch surgery, the potential risks of deep hypothermic circulatory arrest with or without antegrade cerebral perfusion have been widely documented. We hereby describe our early experience with a "branch-first continuous perfusion" technique that, by avoiding deep hypothermia and circulatory arrest, has the potential to reduce morbidity and mortality.

Arterial perfusion is peripheral using femoral and axillary inflows. Disconnection of each arch branch, and anastomosis to the trifurcation graft, proceeds sequentially from the innominate to the left subclavian artery, with continuous perfusion of the heart and viscera by lower body and brain by upper body arterial return. After the descending aorta is clamped, the debranched arch may then be replaced and connected to the ascending aorta before the common stem of the trifurcation graft is joined to the arch graft. Thirty patients underwent this technique. Twelve patients were operated on for aortic dissection and the remainder for aneurysms.

With experience, minimum pump temperature rose from 16°C to 34°C. There was 1 (3.3%) death, and 2 (6.7%) patients had neurological dysfunction. Extubation was achieved within 24 hours in 12 (40%) patients, whereas 14 (47%) left the intensive care unit within 2 days. Ten (33%) patients were discharged from the hospital within 7 days. Eight (27%) patients required no transfusion of blood or blood products.

This technique brings us closer to the goal of arch surgery without cerebral or visceral circulatory arrest and the morbidity of deep hypothermia. Early results are encouraging.