Warm aortic arch repair: A new approach

We present a streamlined approach for aortic arch repair that does not require hypothermic circulatory arrest or axillary/femoral cutdown.

The procedure setup comprised standard right radial/femoral arterial lines, near-infrared spectroscopy, sternotomy, and cardiopulmonary bypass with arch central cannulation. Under normothermia, antegrade cerebral perfusion (ACP) was administered through the innominate artery via punctured aortic root needle cannula (closed ACP) or balloon catheter (open ACP). Aortic arch clamping followed, with bilateral ACP employed in selected cases. From 2019 to 2024, a total of 153 patients, including 48 (30.4%) with Type A aortic dissection, underwent warm arch repair.

The majority of repairs involved hemiarch (n = 137 [89.5%]), with a smaller subset of patients with zone 1 (n = 5 [3.3%]) and zone 2 (n = 11 [7.2%]) arch repair. The volume of warm arch repair cases increased during the study period, with its establishment as the standard approach since 2023, regardless of aortic pathologies. Median ACP flow rates were 8.6 mL/kg/minute and 11.3 mL/kg/minute for unilateral and bilateral ACP, respectively, with a technical success rate of 99.4%. In-hospital mortality and disabling stroke were 2.0% and 1.3%, respectively. Since the launch of this approach and initial experience, 4 surgeons at our institution have adopted this technique and the clinical indications for this approach have evolved.

Warm aortic arch repair without hypothermic circulatory arrest or axillary/femoral cutdown is demonstrated to be safe, feasible, and reproducible. It has emerged as a new and valid approach for various aortic pathologies requiring hemiarch and selected partial aortic arch repair.