Long-term outcomes of total arch replacement with bilateral antegrade cerebral perfusion using the “arch first” approach

Abstract

Objective: To report outcomes of total arch replacement (TAR) with hypothermic circulatory arrest and bilateral antegrade cerebral perfusion (bACP) using an “arch first” approach for acute Type A aortic dissection (ATAAD). The “arch first” approach involved revascularization of the aortic arch branch vessels with uninterrupted ACP, before lower body circulatory arrest, while the patient was cooling. Methods: This was an observational study of aortic surgeries from 2010 to 2021. All patients who underwent TAR with bACP for ATAAD were included. Short-term and long-term outcomes were reported utilizing descriptive statistics and Kaplan-Meier survival estimation. Results: A total of 215 patients were identified who underwent TAR + bACP for ATAAD. Age was 59.0 [49.0–67.0] years and 35.3% were female. 73 patients (34.0%) underwent a concomitant aortic root replacement, 188 (87.4%) had aortic cannulation, circulatory arrest time was 37.0 [26.0–52.0] minutes, and nadir temperature was 20.8 [19.4–22.5] degrees Celsius. 35 patients (16.3%) had operative mortality (STS definition), 17 (7.9%) had a new stroke, 79 (36.7%) had prolonged mechanical ventilation (>24 h), 35 (16.3%) had acute renal failure (by RIFLE criteria), and 128 (59.5%) had blood product transfusions. One-year survival was 77.1%, while 5-years survival was 67.1%. During follow-up, there were 23 (10.7%) reinterventions involving the descending thoracic aorta – either thoracic endovascular aortic repair or open thoracoabdominal aortic replacement. Conclusions: Among patients with ATAAD, short-term postoperative outcomes after TAR + bACP using the “arch first” approach are acceptable. Moreover, this operative strategy may furnish long-term durability, with a reasonably low reintervention rate and satisfactory overall survival.