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SummaryAortic arch surgery requires complex patient management beyond the manual replacement of the diseased vessel. These procedures include (i) a thorough and pathologically adjusted preoperative evaluation, (ii) initiation and control of cardiopulmonary bypass, (iii) cerebral protection strategies and (iv) techniques to protect the abdominal end organs during prolonged operations. Due to the complexity of aortic arch procedures, multimodal real-time surveillance is required during all stages of the operation. Although having the patient survive the operation is the major goal, further observation is necessary because of the chronicity of the disease. This review summarizes specific aspects of patient management during and after operations requiring periods of circulatory arrest, without necessarily referring to all studies on this topic. The pros and cons of different strategies are weighed against each other, including the personal experience of the authors. A number of questions are raised without providing a 'right' or 'wrong' answer. We show that a number of different well-established strategies can result in comparable excellent long-lasting surgical results.

No guidelines for mechanical circulatory support in patients with therapy-refractory cardiogenic shock and multiorgan failure including ongoing cardiopulmonary resuscitation (CPR) exist. To achieve immediate cardiopulmonary stabilization, we established an interdisciplinary concept with on-site percutaneous extracorporeal life support (ECLS) implantation. From February 2012 to November 2014, 96 patients were deemed eligible for ECLS implantation. Establishing ECLS was successful in 87 patients (mean age 54 +/- 13 years, 16% female, initial flow 4.4 +/- 0.9 l/min). Aetiologies included acute coronary syndromes (n = 52, 60%), cardiomyopathies (n = 25, 29%) and other pathologies. Fifty-nine patients (68%) had been resuscitated, and in 27 (31%), implantation was performed during CPR;11 patients (13%) were awake at implantation and 20 (23%) underwent implantation in the referring hospital. Metabolic parameters differed in non-survivors versus survivors before ECLS implantation (pH 7.15 +/- 0.23 vs. 7.27 +/- 0.18, P = 0.007;lactate levels 10.90 +/- 6.00 mmol/l vs. 8.79 +/- 5.78 mmol/l, P = 0.091) and 6 h postimplantation (pH 7.27 +/- 0.11 vs. 7.37 +/- 0.11, P < 0.001;lactate levels 10.19 +/- 5.52 mmol/l vs. 5.52 +/- 4.17 mmol/l, P < 0.001). Altogether 44 patients could be weaned, and 9 were bridged to assist device implantation and 1 to heart transplantation. The mean time of support was 6 days, and the 30-day survival rate was 47% (n = 41). ECLS serves as a bridge-to-decision and bridge-to-treatment device. Our interdisciplinary ECLS programme achieved acceptable survival of critically ill patients despite a substantial percentage of patients having been resuscitated and no absolute exclusion criteria. Further studies defining inclusion- and exclusion criteria might additionally improve outcome.