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Cerebral Protection With Deep Hypothermic Circulatory Arrest During Total Arch Replacement Using the Arch-First

Kimiaki Okada1, Sohsyu Kotani1, Keisuke Ozawa1

  • 1Cardiovascular Surgery, Tokai University School of Medicine, Kanagawa, JPN.

Cureus
|August 12, 2024
PubMed
Summary

Deep hypothermic circulatory arrest (DHCA) during total arch replacement (TAR) is effective for cerebral protection. However, patients with acute aortic dissection (AAD) face higher stroke and mortality risks compared to aneurysm patients.

Keywords:
acute type a aortic dissectiondeep hypothermic circulatory arrest(dhca)dissection with patent false lumenstroke due to air embolismtotal arch replacement

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Area of Science:

  • Cardiovascular Surgery
  • Thoracic Surgery
  • Vascular Surgery

Background:

  • Stroke is a significant complication following total arch replacement (TAR).
  • Deep hypothermic circulatory arrest (DHCA) is commonly used during TAR to prevent stroke.
  • The arch-first technique under DHCA is a critical approach, especially for acute aortic dissection (AAD).

Purpose of the Study:

  • To evaluate the effectiveness of cerebral protection using DHCA during TAR with the arch-first technique.
  • To specifically assess outcomes in patients with AAD compared to those with non-ruptured aneurysms.
  • To identify predictors of stroke after TAR in AAD patients.

Main Methods:

  • Retrospective analysis of 109 AAD patients and 147 aneurysm patients undergoing TAR with the arch-first technique under DHCA.
  • Review of major adverse events, including stroke and 30-day mortality.
  • Multivariable analysis to determine factors influencing stroke occurrence in AAD patients.

Main Results:

  • Stroke occurred in 10.1% of AAD patients versus 2.0% of aneurysm patients (P = 0.005).
  • 30-day mortality was higher in AAD patients (9.2%) compared to aneurysm patients (1.4%) (P = 0.003).
  • Arch vessel dissection with a patent false lumen was the sole significant predictor of stroke in AAD patients (OR, 33.02; P < 0.001).

Conclusions:

  • Patients with aneurysms had significantly better outcomes (fewer strokes, lower mortality) than AAD patients after TAR under DHCA.
  • Cerebral protection with DHCA during TAR using the arch-first technique remains a viable strategy.
  • In AAD patients, stroke after TAR is linked to air emboli from residual dissection in repaired arch vessels.