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Is the branched graft technique better than the en bloc technique for total aortic arch replacement?
Malakh Shrestha1, Andreas Martens, Sylke Behrendt
1Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.
Objectives:
Total aortic arch replacement remains a surgical challenge. For the reimplantation of the supra-aortic vessels, either the en bloc (island) or branched graft technique (BGT) is used. The BGT has been proposed to have several advantages over the classical island technique. The purpose of this study was to compare the perioperative and mid-term follow-up results of these two methods.
Methods:
From March 2006 to December 2010, 103 patients (74.8% male, age 59 ± 12 years) underwent total aortic arch replacement. In 45.6% of the patients (n = 47), branched grafts (Group A, 35 males, 58 ± 13 years) were used, while 54.4% of the patients (n = 56) underwent en bloc technique (Group B, 42 males, 60 ± 12 years). Concomitant procedures were performed as necessary. Twenty-nine (28.2%) patients had an aortic aneurysm [Group A: n = 12 (25.5%), Group B: n = 17 (30.4%)] and 74 (71.8%) patients had an aortic dissection [Group A: n = 35 (74.5%), Group B: n = 39 (69.6%)]. Thirty-one (30.1%) of these patients [Group A: 17 (36.2%), Group B: 14 (25%)] had undergone previous cardiac operations.
Results:
Cardiopulmonary bypass, cross-clamp and circulatory arrest times were 243 ± 71, 140 ± 55 and 53 ± 28 min in Group A and 249 ± 76, 147 ± 54 and 57 ± 30 min in Group B, respectively (P = n.s.). The overall 30-day mortality was 10.6% in Group A and 16.1% in Group B (P = n.s.). The postoperative stroke rate was 4.3% in Group A and 3.8% in Group B, respectively (P = n.s.). Rethoracotomy due to bleeding was 27.7% in Group A and 23.2% in Group B (P = n.s.). At a mean follow-up of 4.0 years, 61.7% of the patients in Group A were alive and 29.8% had undergone operations on the downstream aorta. In Group B, 60.7% of the patients were alive at a mean follow-up of 4.4 years and 20.0% had undergone operations on the downstream aorta. None of the patients in Group B developed further pathological changes in the 'island' or the proximal supra-aortic vessels.
Conclusions:
The BGT is not inferior perioperatively or in the mid-term follow-up compared with the classical island technique. Thus, this technique can be used during total arch replacements in most aortic arch pathologies.