Contemporary surgical techniques and outcomes in total arch replacement: Focus on cerebral and end-organ protection

ObjectiveTo describe the clinical characteristics, operative data, and outcomes of total aortic arch replacement (TAR) performed at a high-volume aortic dedicated center, with a focus on technical aspects and neurologic protection.MethodsWe conducted a retrospective analysis of 536 consecutive patients who underwent TAR between 1997 and 2025. Data were collected from a prospectively maintained institutional database. All procedures were performed via median sternotomy with deep hypothermic circulatory arrest (DHCA) and retrograde cerebral perfusion (RCP) for neuroprotection. Arch reconstruction was performed using either island or debranching techniques, based on patient anatomy and comorbidities. Multivariable Cox regression analysis was used to identify predictors of 10-year mortality.ResultsThe mean patient age was 66.9 ± 12.9 years; 41% were female and 36.8% underwent redo operations. The mean cardiopulmonary bypass time was 158.1 ± 34.7 min, cardiac ischemic time was 102.8 ± 40.7 min, and mean circulatory arrest time was 40 ± 12.8 min. Concomitant procedures were performed in 49.6% of patients. Operative mortality was 2.1%, stroke occurred in 2.6%, and renal complications occurred in 3.2%. The 10-year survival rate was 80.7%. Multivariable analysis identified pulmonary disease, renal impairment, larger aneurysm size, and urgent/emergent presentation as independent predictors of late mortality. The use of RCP provided effective cerebral protection across a wide range of operative complexity.ConclusionTotal aortic arch replacement can be performed with low mortality and excellent long-term outcomes using DHCA with RCP. A tailored operative approach and institutional experience are key to optimizing outcomes.