Open aortic arch replacement in the era of endovascular techniques

Despite the progress in protection and surgical techniques, the proponents of endovascular techniques for aortic arch repair still consider conventional arch replacement to be high risk, mostly due to deep hypothermia, which in the past was generally used for cerebral and organ protection. The aim of the study was to evaluate the operative results of open aortic arch replacement using current perfusion and surgical techniques in which deep hypothermia is avoided.

Between October 2004 and February 2012, 131 consecutive patients with non-acute-dissected aortic arch pathology (mean age: 66 ± 11 years) were referred for surgery. All patients were operated on conventionally using circular aortic arch replacement with repair of one (10), two (58) or all arch branches (63). The adjacent aorta was replaced in all cases (ascending--115, descending--2 and both--14). Nine (6.9%) patients had previous neurological defects with residual symptoms and 17 (13.0%) had previous cardiac surgery.

Either unilateral (130) or bilateral (1) cerebral perfusion at a blood temperature of 28°C (mean duration 36 ± 14, range: 16-80 min) was performed for brain protection during circulatory arrest under mild-to-moderate hypothermia (mean rectal temperature 30.0 ± 1.6°C). Concomitant cardiac procedures, mostly on the aortic valve, were necessary in 121 (92%) patients. Among 114 patients needing aortic valve/root surgery, there were 70 aortic valve-preserving procedures. Permanent neurological deficit or temporary dysfunctions occurred in 1 (0.8%) and 6 patients (4.6%), respectively. No patient suffered from paraplegia. The postoperative 30-day mortality was 2.3% (3 patients). A total of 17 patients died during the follow-up time of up to 97 months (mean 37 ± 27 months), resulting in an actuarial survival of 81.9 ± 4.3% at 5 years. No patient needed any reoperation or new intervention on the repaired aorta.

Conventional arch surgery offers definitive repair and can be safely performed using current perfusion and operative techniques. Open procedures ensure simultaneous aortic valve repair, which is frequently necessary, and can be performed by reconstruction in more than half of the cases. The use of refined surgical and cerebral perfusion techniques allows the avoidance of deep hypothermia with all its negative side effects and leads to excellent outcomes against which the results of alternative approaches should be compared.