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The ability to provide antegrade cerebral and systemic perfusion simultaneously may negate the requirement for any prolonged period of circulatory arrest during complex aortic arch reconstruction procedures, depending on the cannulation strategy. We describe the development and successful implementation of a custom 'split arterial line' extracorporeal circuit configuration to facilitate complex aortic surgery. This circuit design offers a wide range of cannulation and perfusion strategies, is safe, adaptable, simple to manage, and avoids the use of roller pumps for blood delivery, which are associated with deleterious haematological complications during prolonged cardiopulmonary bypass cases. The split arterial line approach has now become the standardised methodology for facilitating complex aortic surgery at our institution. [ABSTRACT FROM AUTHOR]

Background: Selective antegrade cerebral perfusion (SACP) is adopted as an alternative to deep hypothermic circulatory arrest (DHCA) during aortic arch surgery. However, there is still no preclinical evidence to support the use of SACP associated with moderate hypothermia (28–30°C) instead of DHCA (18–20°C). The present study aims to develop a reliable and reproducible preclinical model of cardiopulmonary bypass (CPB) with SACP applicable for assessing the best temperature management. Materials and methods: A central cannulation through the right jugular vein and the left carotid artery was performed, and CPB was instituted. Animals were randomized into two groups: normothermic circulatory arrest without or with cerebral perfusion (NCA vs SACP). EEG monitoring was maintained during CPB. After 10 min of circulatory arrest, rats underwent 60 min of reperfusion. After that, animals were sacrificed, and brains were collected for histology and molecular biology analysis. Results: Power spectral analysis of the EEG signal showed decreased activity in both cortical regions and lateral thalamus in all rats during the circulatory arrest. Only SACP determined complete recovery of brain activity and higher power spectral signal compared to NCA (p < 0.05). Histological damage scores and western blot analysis of inflammatory and apoptotic proteins like caspase-3 and Poly-ADP ribose polymerase (PARP) were significantly lower in SACP compared to NCA. Vascular endothelial growth factor (VEGF) and RNA binding protein 3 (RBM3) involved in cell-protection mechanisms were higher in SACP, showing better neuroprotection (p < 0.05). Conclusions: SACP by cannulation of the left carotid artery guarantees good perfusion of the whole brain in this rat model of CPB with circulatory arrest. The present model of SACP is reliable, repeatable, and not expensive, and it could be used in the future to achieve preclinical evidence for the best temperature management and to define the best cerebral protection strategy during circulatory arrest. [ABSTRACT FROM AUTHOR]

Objectives: Acknowledging lacking of consensus exist in total aortic arch (TAA) surgery for acute type A aortic dissection (AAD), this study aimed to investigate the neurologic injury rate between bilateral and unilateral cerebrum perfusion on the specific population. Methods: A total of 595 AAD patients other than Marfan syndrome receiving TAA surgery since March 2013 to March 2022 were included. Among them, 276 received unilateral cerebral perfusion (via right axillary artery, RCP) and 319 for bilateral cerebral perfusion (BCP). The primary outcome was neurologic injury rate. Secondary outcomes were 30-day mortality, serum inflammation response (high sensitivity C reaction protein, hs-CRP; Interleukin-6, IL-6; cold-inducible RNA binding protein, CIRBP) and neuroprotection (RNA-binding motif 3, RBM3) indexes. Results: The BCP group reported a significantly lower permanent neurologic deficits [odds ratio: 0.481, Confidence interval (CI): 0.296–0.782, p = 0.003] and 30-day mortality (odds ratio: 0.353, CI: 0.194–0.640, p < 0.001) than those received RCP treatment. There were also lower inflammation cytokines (hr-CRP: 114 ± 17 vs. 101 ± 16 mg/L; IL-6: 130 [103,170] vs. 81 [69,99] pg/ml; CIRBP: 1076 [889, 1296] vs. 854 [774, 991] pg/ml, all p < 0.001), but a higher neuroprotective cytokine (RBM3: 4381 ± 1362 vs 2445 ± 1008 pg/mL, p < 0.001) at 24 h after procedure in BCP group. Meanwhile, BCP resulted in a significantly lower Acute Physiology, Age and Chronic Health Evaluation (APACHE) Ⅱscore (18 ± 6 vs 17 ± 6, p < 0.001) and short stay in intensive care unit (4 [3,5] vs. 3 [2,3] days, p < 0.001) and hospital (16 ± 4 vs 14 ± 3 days, p < 0.001). Conclusions: This present study indicated that BCP compared with RCP was associated with lower permanent neurologic deficits and 30-day mortality in AAD patients other than Marfan syndrome receiving TAA surgery. [ABSTRACT FROM AUTHOR]

Coarctation of the aorta is a common congenital abnormality that may be associated with serious and rare anomalies like aneurysms. Severe coarctation or interrupted aortic arch in adults is usually managed by percutaneous interventions or extra-anatomic bypass. However, the presence of an aneurysm beyond the coarcted segment implies the opening of a collateral-rich segment of the aorta with redressal of the arch if hypoplastic. We describe our experience in managing three such patients through antero-lateral thoracotomy with antegrade cerebral perfusion. We have found this technique helpful in treating aneurysms of the distal aortic arch or proximal descending thoracic aorta. [ABSTRACT FROM AUTHOR]

OBJECTIVES The aim of this multicentre study was to demonstrate the safety and clinical performance of E-vita OPEN NEO Stent Graft System (Artivion, Inc.) in the treatment of aneurysm or dissection, both acute and chronic, in the ascending aorta, aortic arch and descending thoracic aorta. METHODS In this observational study of 12 centres performed in Europe and in Asia patients were enrolled between December 2020 and March 2022. All patients underwent frozen elephant trunk using E-vita OPEN NEO Stent Graft System. Primary end point was the rate of all-cause mortality at 30 days and secondary end points included further clinical and safety data are reported up to 3–6 months postoperatively. RESULTS A total of 100 patients (66.7% male; mean age, 57.7 years) were enrolled at 12 sites. A total of 99 patients underwent surgery using the E-vita OPEN NEO for acute or subacute type A aortic dissection (n  = 37), chronic type A aortic dissection (n  = 33) or thoracic aortic aneurysm (n  = 29), while 1 patient did not undergo surgery. Device technical success at 24 h was achieved in 97.0%. At discharge, new disabling stroke occurred in 4.4%, while new paraplegia and new paraparesis was reported in 2.2% and 2.2%, respectively. Renal failure requiring permanent (>90 days) dialysis or hemofiltration at discharge was observed in 3.3% of patients. Between discharge and the 3–6 months visit, no patients experienced new disabling stroke, new paraplegia or new paraparesis. The 30-day mortality was 5.1% and the estimated 6-month survival rate was 91.6% (standard deviation: 2.9). CONCLUSIONS Total arch replacement with the E-vita OPEN NEO can be performed with excellent results in both the acute and chronic setting. This indicates that E-vita OPEN NEO can be used safely, including in the setting of acute type A aortic dissection. [ABSTRACT FROM AUTHOR]

Acute type A aortic dissection (ATAAD) is a surgical emergency with a mortality of 1–2% per hour. Since its discovery over 200 years ago, surgical techniques for repairing a dissected aorta have evolved, and with the introduction of hypothermic circulatory arrest and cerebral perfusion, complex techniques for replacing the entire aortic arch were possible. However, postoperative neurological complications contribute significantly to mortality in this group of patients. The aim of this study was to determine the association between different bilateral selective antegrade cerebral perfusion (ACP) times and the incidence of postoperative ischemic stroke in patients with emergency surgery for ATAAD. Patients with documented hemorrhagic or ischemic stroke, clinical signs of stroke or neurological dysfunction prior to surgery, that died on the operating table or within 48 h after surgery, from whom the postoperative neurological status could not be assessed, and with incomplete medical records were excluded from this study. The diagnosis of postoperative stroke was made using head computed tomography imaging (CT) when clinical suspicion was raised by a neurologist in the immediate postoperative period. For selective bilateral antegrade cerebral perfusion, we used two balloon-tipped cannulas inserted under direct vision into the innominate artery and the left common carotid artery. Each cannula is connected to a separate pump with an independent pressure line. Near-infrared spectroscopy was used in all cases for cerebral oxygenation monitoring. The circulatory arrest was initiated after reaching a target core temperature of 25–28 °C. In total, 129 patients were included in this study. The incidence of postoperative ischemic stroke documented on a head CT was 24.8% (31 patients), and postoperative death was 20.9% (27 patients). The most common surgical technique performed was supravalvular ascending aorta and Hemiarch replacement with a Dacron graft in 69.8% (90 patients). The mean cardiopulmonary bypass time was 210 +/− 56.874 min, the mean aortic cross-clamp time was 114.775 +/− 34.602 min, and the mean cerebral perfusion time was 37.837 +/− 18.243 min. Using logistic regression, selective ACP of more than 40 min was independently associated with postoperative ischemic stroke (OR = 3.589; 95%CI = 1.418–9.085; p = 0.007). Considering the high incidence of postoperative stroke in our study population, we concluded that bilateral selective ACP should be used with caution, especially in patients with severely calcified ascending aorta and/or aortic arch and supra-aortic vessels. All efforts should be made to minimize the duration of circulatory arrest when using bilateral selective ACP with a target of less than 30 min, in hypothermia, at a body temperature of 25–28 °C. [ABSTRACT FROM AUTHOR]

Objective: Axillary and innominate artery (IA) cannulation using side graft has some limitations in patients having ascending aortic dissection (AAD) with flap extending in major neck vessels. We retrospectively analyzed the outcomes of a direct under vision innominate ostial cannulation strategy for antegrade cerebral perfusion (ACP) using a retrograde balloon-tip cardioplegia cannula. Patients and Methods: This was a retrospective analysis of all patients who were operated on for AAD with a dissection flap extending into major neck vessels between November 01, 2020 and November 30, 2022. Demographic data were noted, and comorbidities were listed. The kind of surgery patients underwent was noted: three patients underwent modified Bentall's procedure, five had to ascend aortic replacement, and one patient underwent David's procedure. All patients had open distal anastomosis using moderate hypothermia with ACP by direct under vision cannulation of the true lumen of the IA using a balloon-tip retrograde cardioplegia cannula. Intraoperative parameters such as cross-clamp time, cardiopulmonary bypass time, temperature range during circulatory arrest, and total operative time were noted. The primary outcome was a comparison of the incidence of stroke, seizures, and psychosis and the secondary outcome was an analysis of end-organ malperfusion, intensive care unit (ICU) stays, total hospital stay, and 30-day mortality. Results: We retrospectively analyzed the surgical data of nine patients who were operated on between November 01, 2020 and November 20, 2022 by this technique and found that the incidence of stroke, seizures organ malperfusion, ICU stay, and hospital stay was comparable to other techniques of ACP (axillary artery/direct IA cannulation), but the operative time was a less, and local complications due to axillary cannulation such as shoulder pain and upper limb weakness and seroma were not seen. Conclusion: Direct vision cannulation of the true lumen of the IA using a retrograde balloon-tip cannula is a cost-effective and time-saving method. It evades the limitations of well-established ACP techniques such as direct IA cannulation using Seldinger's technique which is a blind procedure and also has no local complications of the cannulating right axillary artery. Our results show that this procedure is less time-consuming and is noninferior to the other two methods of ACP in patients getting operated on for AAD with open distal anastomosis under moderate hypothermia. Further studies with a larger sample size are needed to validate this preliminary study.

Background: Cannulation strategies in ascending aorta and arch surgeries are a matter of immense discussion. Majority of time deep hypothermic circulatory arrest (DHCA) is the preferred strategy, but it does come with its set of demerits. Double-arterial cannulation (DAC) may decrease DHCA time and avoid its related morbidity and mortality. Aim: The aim was to compare patients undergoing surgery in acute Type A dissection by DAC with antegrade cerebral perfusion under moderate hypothermia and single-arterial cannulation (SAC) technique under DHCA with respect to the primary outcome of stroke, seizure, and psychosis and the secondary outcome as malperfusion, hospital stay, and mortality. Materials and Methods: This study was a retrospective analysis of 64 patients operated for acute ascending aortic dissection (AAD) extending into arch and major vessels in the Department of CTVS, UN Mehta Institute of Cardiology and Research between July 2015 and July 2020. After screening through the hospital data, 30 patients operated by SAC and 34 patients operated by DAC technique were selected and their files were studied and analyzed. All patients were diagnosed using two-dimensional echocardiogram and computerized tomography aortogram to confirm the diagnosis. Forty-four patients who presented to emergency were stabilized before taking up for emergency surgery and 20 were operated semi-electively. Out of 64 patients, 40 patients underwent Bentall's procedure using composite mechanical valve, 10 patients underwent ascending aorta replacement, 7 patients underwent ascending aorta replacement with hemiarch, 2 patients underwent Bentall's with coronary artery bypass grafting, 2 patients underwent David's procedure, 2 patients underwent Yacoub's procedure, and 1 patient underwent Bentall's procedure using biological valve. Out of 30 patients operated by SAC, 25 patients had femoral cannulation and 5 patients had only right axillary cannulation. In the DAC group, all had right axillary artery and femoral cannulation. All patients were analyzed for primary and secondary outcomes. Results: A total of 64 patients diagnosed with Type A AAD with dissection flap extending into major vessels were included in the study. Those patients operated with DAC technique had a significantly lower incidence of stroke, malperfusion, and hospital mortality as compared to the patients with SACs. Conclusion: In AAD involving major arch vessel and femoral arteries, the idea is to provide rapid and safe blood inflow to arterial system in order to maintain cardiopulmonary bypass (CPB) and organ perfusion, which is of utmost iimportance. The idea is to provide rapid and safe blood inflow to arterial system in order to maintain cardiopulmonary bypass (CPB) and organ perfusion, which is of utmost importance. The right axillary artery is least involved in acute aortic dissection and when cannulated can provide uninterrupted flow to brain and also provide sufficient inflow to maintain CPB. Along with this, if femoral artery cannulation provides flow to abdominal organs and lower limb, it will prevent malperfusion syndrome. DAC is safe in complex Type A aortic dissection and aortic arch surgery and has better perioperative outcomes compared to SAC.

BackgroundSurgical procedures involving the aortic arch present unique challenges to maintaining cerebral perfusion, and optimal neuroprotective strategies to prevent neurological injury during such high-risk procedures are not completely understood. The use of antegrade cerebral perfusion (ACP) has gained favor as a neuroprotective strategy over deep hypothermic circulatory arrest (DHCA) due to the ability to selectively perfuse the brain. Despite this theoretical advantage over DHCA, there has not been conclusive evidence that ACP is superior to DHCA. One potential reason for this is the incomplete understanding of ideal ACP flow rates to prevent both ischemia from underflowing and hyperemia and cerebral edema from overflowing. Critically, there are no continuous, noninvasive measurements of cerebral blood flow (CBF) and cerebral oxygenation (StO2) to guide ACP flow rates and help develop standard clinical practices. The purpose of this study is to demonstrate the feasibility of using noninvasive, diffuse optical spectroscopy measurements of CBF and cerebral oxygenation during the conduct of ACP in human neonates undergoing the Norwood procedure.MethodsFour neonates prenatally diagnosed with hypoplastic left heart syndrome (HLHS) or a similar variant underwent the Norwood procedure with continuous intraoperative monitoring of CBF and cerebral oxygen saturation (StO2) using two non-invasive optical techniques, namely diffuse correlation spectroscopy (DCS) and frequency-domain diffuse optical spectroscopy (FD-DOS). Changes in CBF and StO2 due to ACP were calculated by comparing these parameters during a stable 5 min period of ACP to the last 5 min of full-body CPB immediately prior to ACP initiation. Flow rates for ACP were left to the discretion of the surgeon and ranged from 30 to 50 ml/kg/min, and all subjects were cooled to 18°C prior to initiation of ACP.ResultsDuring ACP, the continuous optical monitoring demonstrated a median (IQR) percent change in CBF of −43.4% (38.6) and a median (IQR) absolute change in StO2 of −3.6% (12.3) compared to a baseline period during full-body cardiopulmonary bypass (CPB). The four subjects demonstrated varying responses in StO2 due to ACP. ACP flow rates of 30 and 40 ml/kg/min (n = 3) were associated with decreased CBF during ACP compared to full-body CPB. Conversely, one subject with a higher flow6Di rate of 50 ml/kg/min demonstrated increased CBF and StO2 during ACP.ConclusionsThis feasibility study demonstrates that novel diffuse optical technologies can be utilized for improved neuromonitoring in neonates undergoing cardiac surgery where ACP is utilized. Future studies are needed to correlate these findings with neurological outcomes to inform best practices during ACP in these high-risk neonates.

Retrograde cerebral perfusion (RCP) is a safe and effective technique to augment cerebral protection during lower body circulatory arrest in patients undergoing elective hemiarch replacement. However, recommendations guiding optimal temperature, flow rate, and perfusion pressure are outdated and potentially overly limiting. We report our experience using RCP for elective hemiarch replacement with parameters that challenge the currently accepted paradigm. This was a single-center, retrospective analysis of 319 adult patients who underwent elective hemiarch replacement between February 2010 and 2021 using hypothermic lower body circulatory arrest with RCP alone, RCP followed by antegrade cerebral perfusion (ACP), or ACP alone. Flow rates were adjusted to maintain cerebral perfusion pressure between 30 and 50 mm Hg for RCP and between 40 and 60 mm Hg for ACP. RCP was used in 22.6% (n = 72) of cases, whereas ACP alone was performed in 77.4% (n = 247) of cases. Baseline patient characteristics were similar between groups. Patients undergoing RCP demonstrated shorter cross-clamp time (97.0 min versus 100.0 min, P = 0.034) and shorter lower body circulatory arrest time (7.0 min versus 10.0 min, P < 0.0001) compared with ACP alone. Nadir bladder temperature was equivalent between groups (27.3°C versus 27.5°C, P = 0.752). There were no significant differences in postoperative complications, neurologic outcomes, or mortality. Moderate hypothermic lower body circulatory arrest combined with RCP at target perfusion pressures of 30-50 mm Hg in patients undergoing elective hemiarch replacement results in equivalent neurologic outcomes and overall morbidity to cases using ACP alone. These results challenge the currently accepted paradigm for RCP, which typically uses deep hypothermia while keeping perfusion pressures below 25 mm Hg. [ABSTRACT FROM AUTHOR]

Background: The optimal hypothermic circulatory arrest (HCA) temperature during total arch replacement (TAR) and the impact of HCA temperature on postoperative neurological complications are still uncertain., Objective: The aim of this study is to explore the impact of HCA temperature on short-term postoperative outcomes, especially neurological complications, for patients who undergo TAR., Methods: We retrospectively analyzed data of 2351 patients who underwent TAR at one of seven selected aortic centers from January 2016 to June 2023. Restricted cubic splines (RCS) and subgroup analyses were performed to determine the relation between temperature and outcomes under different cerebral perfusion methods, cannulation strategies, diagnoses, and surgical timings., Results: The overall in-hospital mortality was 6.2% (n = 146). The incidence of stroke, paraplegia and total-arch composite outcome (TCO) was 6.0% (n = 142), 2.8% (n = 65) and 21.0% (n = 494), respectively. The average HCA temperature was 25.9 ± 1.9 °C, and the median circulatory arrest time was 23 (Q1, Q3: 18, 30) min. Adjusted RCS showed the lowest incidence of stroke, paraplegia, and TCO at temperatures of 26.6 °C, 27.4 °C, and 26.8 °C, but without statistical significance. In subgroup analysis, the unilateral antegrade cerebral perfusion (uACP) group revealed a significant nonlinear relation between HCA temperature and the risk of stroke, and the lowest risk showed at 26.5 °C. Other subgroup analyses did not reveal a significant nonlinear relation between temperature and outcomes., Conclusions: For patients undergoing TAR with uACP, cooling to a temperature of 26-27 °C was associated with the lowest incidence of stroke., (Copyright © 2024. Published by Elsevier Inc.)

Background: For type A aortic dissection (TAAD), antegrade cerebral perfusion (ACP) was proposed as a more physiological method than retrograde cerebral perfusion (RCP) for intra-operative brain protection, but it is still debatable whether antegrade cerebral perfusion (ACP) or retrograde cerebral perfusion (RCP) is related to the better clinical outcome. The present study was undertaken to compare the results in our patients receiving surgery for TAAD with ACP or RCP. The primary aim of this study was focused on the incidence of and the factors associated with surgical mortality, post-operative neurological outcomes and long-term survival. Methods: From February 2001 to March 2019, there were 223 consecutive patients with TAAD treated surgically at our hospital. The median age at presentation was 56 years (range 29–88 years) and 70 patients (31.4%) over 65 years of age. There were 168 patients treated with RCP and 55 patients treated with ACP. The primary endpoints were surgical mortality and neurological outcome. Propensity score matching was used to compare the treatment results of surgeries with RCP or ACP. The long-term survival was also analyzed. Results: The overall in-hospital mortality rate and the overall 30-day mortality rate were 15.6% and 14.3% respectively. For the patients without pre-operative shock (n = 184), the in-hospital mortality rate was 10.3% and the 30-day mortality rate was 8.7% and higher long-term survival rates (88.3% for 5 years, 86.5% for 10 years, 86.5% for 15 years) were documented for this patient group. There was no significant difference on the surgical mortality between the ACP group and the RCP group. In the entire cohort, there were 23 patients (10.3%) who suffered from post-operative neurological deficits (PND) and there were less PND for the patients with RCP than the patients with ACP (7.7% vs 18.1%, p = 0.027). After propensity score matching, there was still higher incidence of PND in the ACP group than in the RCP group but without statistical significance (18.5% vs 11.1%, p = 0.279). Conclusions: Aortic surgery carries high risk for the patients with TAAD and PND is not an unusual post-operative morbidity. In our series, pre-operative shock, pre-operative CPR, CRI, past history with CAD are related to higher surgical mortality. The younger patients (

Acute type A aortic dissection (ATAAD) is a surgical emergency with a mortality of 1–2% per hour. Since its discovery over 200 years ago, surgical techniques for repairing a dissected aorta have evolved, and with the introduction of hypothermic circulatory arrest and cerebral perfusion, complex techniques for replacing the entire aortic arch were possible. However, postoperative neurological complications contribute significantly to mortality in this group of patients. The aim of this study was to determine the association between different bilateral selective antegrade cerebral perfusion (ACP) times and the incidence of postoperative ischemic stroke in patients with emergency surgery for ATAAD. Patients with documented hemorrhagic or ischemic stroke, clinical signs of stroke or neurological dysfunction prior to surgery, that died on the operating table or within 48 h after surgery, from whom the postoperative neurological status could not be assessed, and with incomplete medical records were excluded from this study. The diagnosis of postoperative stroke was made using head computed tomography imaging (CT) when clinical suspicion was raised by a neurologist in the immediate postoperative period. For selective bilateral antegrade cerebral perfusion, we used two balloon-tipped cannulas inserted under direct vision into the innominate artery and the left common carotid artery. Each cannula is connected to a separate pump with an independent pressure line. Near-infrared spectroscopy was used in all cases for cerebral oxygenation monitoring. The circulatory arrest was initiated after reaching a target core temperature of 25–28 °C. In total, 129 patients were included in this study. The incidence of postoperative ischemic stroke documented on a head CT was 24.8% (31 patients), and postoperative death was 20.9% (27 patients). The most common surgical technique performed was supravalvular ascending aorta and Hemiarch replacement with a Dacron graft in 69.8% (90 patients). The mean cardiopulmonary bypass time was 210 +/− 56.874 min, the mean aortic cross-clamp time was 114.775 +/− 34.602 min, and the mean cerebral perfusion time was 37.837 +/− 18.243 min. Using logistic regression, selective ACP of more than 40 min was independently associated with postoperative ischemic stroke (OR = 3.589; 95%CI = 1.418–9.085; p = 0.007). Considering the high incidence of postoperative stroke in our study population, we concluded that bilateral selective ACP should be used with caution, especially in patients with severely calcified ascending aorta and/or aortic arch and supra-aortic vessels. All efforts should be made to minimize the duration of circulatory arrest when using bilateral selective ACP with a target of less than 30 min, in hypothermia, at a body temperature of 25–28 °C.

Abstract Objectives Antegrade cerebral perfusion (ACP) under moderate hypothermic circulatory arrest is used during total aortic arch replacement surgery (TARS) in patients with acute type A aortic dissection, but it is associated with high mortality and morbidity. We hypothesized that combining ACP with retrograde inferior vena caval perfusion (RIVP) improves outcomes. Methods This pilot study was prospective, randomized, controlled and assessor-blinded. Patients scheduled for TARS were randomly treated with either ACP or RIVP + ACP. The primary outcome was a composite of mortality and major complications including paraplegia, postoperative renal failure, severe liver dysfunction, and gastrointestinal complications. Secondary outcomes included neurological complications, length of intubation and requirement of blood products. Results A total of 76 patients were recruited (n = 38 per group). Primary outcome occurred in 23 patients (61%) in the ACP group and 16 (42%) in the RIVP + ACP group (OR: 0.60, 95% CI: 0.21–1.62; p = 0.31). There was a lower incidence of transient neurological deficits in the RIVP + ACP group (26% vs. 58%, OR: 0.26; 95% CI: 0.10–0.67,p = 0.006;). The RIVP + ACP group underwent shorter intubation (25 vs 47 h, p = 0.022) and required fewer blood products (red cells, 3.8 units vs 6.5 units, p = 0.047; platelet: 2.0 units vs 2.0 units, p = 0.023) compared with the ACP group. Conclusions RIVP + ACP may be associated with lower incidence of transient neurological deficits, shorter intubation and less blood transfusion requirement than ACP alone during TARS. Multi-center, randomized trials with larger samples are required to determine whether RIVP + ACP is associated with lower rates of mortality and major complications. Trial registration: Pilot study of a RCT registered in clinicaltrials.gov (NCT03607786), Registered 30 July, 2018—Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03607786 .

Sternal reentry for repair of aortic pseudoaneurysms poses a unique technical challenge to prevent exsanguination. Initiation of peripheral cardiopulmonary bypass and deep hypothermic circulatory arrest prior to reentry are the cornerstones of a successful surgical approach. Adjunctive bilateral antegrade cerebral perfusion increases safe arrest time and reduces neurologic morbidity. Herein, we describe our safe reentry technique for aortic pseudoaneurysm repair in two patients. [ABSTRACT FROM AUTHOR]

Background: Persistence or recurrence of stenosis is a complication of initial coarctation repair. This study aims to report short‐term outcomes of surgical management of recurrent coarctation and initial repair analysis. Methods: We retrospectively reviewed our experience with 51 patients undergoing recoarctation surgical repair between 2008 and 2019 using antegrade cerebral perfusion (ACP) technique. Results: Surgical correction included prosthetic patch aortoplasty in 23 (45%), resection with wide end‐to‐end anastomosis in 15 (29%), and a tube interposition graft in 13 (25%) patients. The median age at initial correction and reintervention was 12 months and 9 years. The median interval from primary repair to reintervention was 60 months. Initial repair analysis revealed 33% of patients had initial correction in the neonatal period, 72.5% of patients were done via a left thoracotomy approach and 63% of patients had end‐to‐end anastomosis at initial surgery. Conclusion: Our study demonstrates that surgical repair of recurrent coarctation of the aorta using ACP technique can be performed safely and with excellent results. [ABSTRACT FROM AUTHOR]

The "Branch-First total arch replacement" technique has been used extensively in both elective and acute situations, including in type A aortic dissection. The focus of the Branch-First technique is to reduce the risk of neurological and end-organ dysfunction associated with arch replacement by optimising neuroprotection, distal organ perfusion and myocardial protection. The Branch-First technique is a valuable alternative to the frozen elephant trunk (FET) technique in type A aortic dissection, providing a stable landing zone for subsequent interventions on the distal aorta should they be required. Combining the Branch-First technique with FET in appropriate cases can further improve outcomes. We discuss the merits of the Branch-First technique, and contrast them to those of FET techniques for repair of type A aortic dissection. [ABSTRACT FROM AUTHOR]

Our current approach towards total arch replacement includes the following: (1) innominate vein mobilization, (2) no neck vessel taping, and no dissection of the vagal nerve, (3) meticulous selection of arterial cannulation site and type of arterial cannula, (4) antegrade cerebral perfusion(ACP)for neuro-protection, utilizing three balloon-tipped cannular from inside the arch, (5) whole-body hypothermia with minimal tympanic temperatures between 20 and 23 °C and minimal rectal temperatures below 30 °C, (6) distal enucleation and felt reinforcement for in zone III distal anastomosis using four branched graft, (7) early re-warming after distal anastomosis with ACP flow adjustment while monitoring brain oxygenation by near-infrared spectroscopy (NIRS) and (8) second anastomosis is proximal and last one is arch vessel reconstruction, (9) maintaining strict fluid balance below 1000 ml by the extracorporeal ultrafiltration method (ECUM) during cardiopulmonary bypass (CPB), with the expectation of more rapid pulmonary functional recovery. [ABSTRACT FROM AUTHOR]

There is considerable debate with regard to the optimal cerebral protection strategy during aortic arch surgery. There are three contemporary techniques in use which include straight deep hypothermic circulatory arrest (DHCA), DHCA with retrograde cerebral perfusion (DHCA + RCP), and moderate hypothermic circulatory arrest with antegrade cerebral perfusion (MHCA + ACP). Appropriate application of these methods ensures appropriate cerebral, myocardial, and visceral protection. Each of these techniques has benefits and drawbacks and ensuring coordinated circulation management strategy is critical to safe performance of aortic arch surgery. In this report, we will review various cannulation strategies, review logistics of hypothermia, and review the relevant literature to outline the strengths and weaknesses of these various cerebral protection strategies. [ABSTRACT FROM AUTHOR]

Objective. To evaluate the psychomotor development of children after aortic arch reconstruction in the conditions of selective antegrade cerebral perfusion. Materials and methods. The results of surgical treatment and psychomotor development of 48 children aged 1 to 3 years, who underwent reconstruction of the aortic arch in terms of artificial circulation and selective antegrade cerebral perfusion at the age of 1 year at the Amosov National Institute of Cardiovascular Surgery and the Scientific and Practical Medical Center of Pediatric Cardiology and Cardiac Surgery in the period from 2014 to 2019 were analyzed. To study the cognitive sphere and motor development of children we used the 2nd edition of the method "Bayley Scales of Infant Development - II". In analyzing the results in children with psychomotor developmental delay, the values of the mental index and the index of psychomotor development were taken into account. Results. 2 (3.7%) patients died after surgery. Postoperative mortality was connected with neurological complications and technique of cerebral perfusion. In the remote period no patient died. According to neurosonography in the postoperative period, no pathological structural changes in the brain were detected. In 16 (33.3%) children at the age of 1 year there was a slight delay in mental and / or psychomotor development. Evaluation of the results of the survey in the dynamics showed that at the age of 3 years, 9 (18.7%) children had a slight development delay. The average values of the mental index in 1 year were 81.2 ± 8.6, and in 3 years - 96.4 ± 12.7 (p

Background: Cardiopulmonary bypass (CPB) may lead to tissue hypoxia, inflammatory response, and risk for acute kidney injury (AKI). We evaluated the prevalence of AKI and inflammatory response in neonates undergoing heart surgery requiring CPB with or without antegrade cerebral perfusion (ACP). Methods: Forty neonates were enrolled. The patients were divided into two groups depending on the use of ACP. AKI was classified based on the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Inflammatory response was measured using plasma concentrations of interleukins 6 (IL-6) and 10 (IL-10), white blood cell count (WBC), and C-reactive protein (CRP). Results: Eight patients (20%) experienced AKI: five (29%) in the ACP group and three (13%) in the non-ACP group (P = 0.25). Postoperative peak plasma creatinine and urine neutrophil gelatinase-associated lipocalin were significantly higher in the ACP group than in the non-ACP group [46.0 (35.0–60.5) vs 37.5 (33.0-42.5), P = 0.044 and 118.0 (55.4–223.7) vs 29.8 (8.1–109.2), P = 0.02, respectively]. Four patients in the ACP group and one in the non-ACP group required peritoneal dialysis (P = 0.003). Postoperative plasma IL-6, IL-10, and CRP increased significantly in both groups. There were no significant differences between the ACP and non-ACP groups in any of the inflammatory parameters measured. Conclusions: No significant difference in the AKI occurrence or inflammatory response related to CPB modality could be found. In our study population, inflammation was not the key factor leading to AKI. Due to the limited number of patients, these findings should be interpreted with caution.

Technical aspects of aortic arch replacement have evolved over the years with significant focus on reducing the risk of operative morbidity and mortality. Recent developments in surgical methods relate to optimizing strategies for neuroprotection, distal organ perfusion and myocardial protection. We describe the branch-first technique for aortic arch replacement using a trifurcation graft with a side perfusion port (TAPP). It simplifies the delivery of continuous antegrade cerebral perfusion, and takes advantage of intracranial and extracranial networks to augment contralateral cerebral perfusion. Consequently, it allows for moderate levels of hypothermia and avoids distal circulatory arrest in many cases. In cases where distal circulatory arrest is required, it affords a longer safe duration of distal arrest and allows aortic pathology to be completely and meticulously corrected without time pressures. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES There have been limited data available regarding aortic arch replacement in dialysis patients. The purpose of this study was to examine real-world data and to determine the impact of preoperative dialysis status and other risks on surgical aortic arch replacement using the Japan Cardiovascular Surgery Database. METHODS A total of 5044 patients who underwent elective, isolated aortic arch replacement using antegrade cerebral perfusion during 2014–2017 were eligible for the study. Of these, 89 patients received haemodialysis preoperatively. The patients were divided into 6 groups according to their preoperative estimated glomerular filtration rate and dialysis status for comparison. Preoperative and postoperative data were examined using a multivariable regression model. RESULTS The overall surgical mortality rates of non-Chronic Kidney Disease (CKD) (estimated glomerular filtration rate >60 ml/min/1.73 m2), stage 3A, stage 3B, stage 4, stage 5 CKD and dialysis patients were 2.6%, 3.1%, 6.8%, 11.6%, 16.7% and 13.5%, respectively. After risk adjustment, dialysis was shown to be strongly associated with surgical mortality (odds ratio 4.39 and 95% confidence interval 2.22–8.72) and have a trend to be associated with postoperative stroke (odds ratio 2.02, 95% confidence interval 1.00–4.10, P  = 0.051) when compared to the non-CKD group. As predictors of mortality, male sex, peripheral arterial disease, preoperative liver dysfunction and impaired left ventricular function were identified. CONCLUSIONS The Japanese nationwide database revealed the outcomes of aortic arch replacement in dialysis patients. Appropriate counselling and an alternative strategy should be considered for such patients with multiple risks for mortality. [ABSTRACT FROM AUTHOR]

We aimed to determine the effects of selective antegrade cerebral perfusion compared with other perfusion strategies on indices of cerebral blood flow, oxygenation, cellular stress, and mitochondrial function. One-week-old piglets (n = 41) were assigned to 5 treatment groups. Thirty-eight were placed on cardiopulmonary bypass. Of these, 30 were cooled to 18°C and underwent deep hypothermic circulatory arrest (n = 10), underwent selective antegrade cerebral perfusion at 10 mL/kg/min (n = 10), or remained on continuous cardiopulmonary bypass (deep hypothermic cardiopulmonary bypass, n = 10) for 40 minutes. Other subjects remained on normothermic cardiopulmonary bypass (n = 8) or underwent sham surgery (n = 3). Novel, noninvasive optical measurements recorded cerebral blood flow, cerebral tissue oxyhemoglobin concentration, oxygen extraction fraction, total hemoglobin concentration, and cerebral metabolic rate of oxygen. Invasive measurements of cerebral microdialysis and cerebral blood flow were recorded. Cerebral mitochondrial respiration and reactive oxygen species generation were assessed after the piglets were killed. During hypothermia, deep hypothermic circulatory arrest piglets experienced increases in oxygen extraction fraction (P <. 001), indicating inadequate matching of oxygen supply and demand. Deep hypothermic cardiopulmonary bypass had higher cerebral blood flow (P =. 046), oxyhemoglobin concentration (P =. 019), and total hemoglobin concentration (P =. 070) than selective antegrade cerebral perfusion, indicating greater oxygen delivery. Deep hypothermic circulatory arrest demonstrated worse mitochondrial function (P <. 05), increased reactive oxygen species generation (P <. 01), and increased markers of cellular stress (P <. 01). Reactive oxygen species generation was increased in deep hypothermic cardiopulmonary bypass compared with selective antegrade cerebral perfusion (P <. 05), but without significant microdialysis evidence of cerebral cellular stress. Selective antegrade cerebral perfusion meets cerebral metabolic demand and mitigates cerebral mitochondrial reactive oxygen species generation. Excess oxygen delivery during deep hypothermia may have deleterious effects on cerebral mitochondria that may contribute to adverse neurologic outcomes. We describe noninvasive measurements that may help guide perfusion strategies. [Display omitted] [ABSTRACT FROM AUTHOR]

The total aortic arch replacement is one of the most technically demanding operations, the main risk of which is the intraoperative ischemic lesion of the brain. Despite progress, operating mortality associated with this operation, even at the most renowned specialized centers reaches 7.3%. An alternative to the classic “open” operation is aortic endoprosthesis, combined with the procedure of debranching. This approach allows diminishing trauma by reducing the duration of the cardiopulmonary bypass. The aim. To describe the rational approach for replacing the total aortic arch depending on the diameter of aneurysm, the condition of the arch vessels, and the acuteness of clinical condition. The main indications for the replacement of the aortic arch are the true atherosclerotic aneurysms, genetic connective tissue diseases (Marfan syndrome), syphilis. The total arch replacement recently becomes more frequent indication for acute type A aortic dissection. The newly introduced strategies of operation and perfusion for total aortic arch replacement are aimed to reduce the risk of neurological complications. This method is named “arch first technique” which gradually replaces the earlier technique, at which the first anastomosis is performed with a descending thoracic aorta. A more traditional method called the “descending aorta first” was selected. A mandatory element of both types of the operation is antegrade cerebral perfusion. The main advantage of this method is maintaining constant perfusion of the brain which significantly reduces the risk of its ischemic damage, avoids deep hypothermia and its negative impact on blood coagulation system. The technique of total arch replacement consists of the following elements: access, double arterial cannulation, the method of brain protection, formation of distal anastomosis with descending thoracic aorta, implantation of arch vessels into the prosthesis. Sequence of anastomosis depends on morphological and clinical peculiarities of the specific case. Changes in the strategy for “open” total aortic arch replacement in various aortic pathologies is discussed based on the author’s clinical experience and literature data. Conclusions. Total aortic arch replacement remains a traumatic and technically demanding operation, the main risks of which are hemorrhage and ischemic brain lesions. The method of arch replacement – “descending aorta first” includes double arterial cannulation, antegrade cerebral perfusion, deep hypothermia with complete blood flow stoppage for the lower half of the body and the use of multi-branch vascular prosthesis.

Aim: This study aims to compare biomarkers related to endothelial function during selective antegrade cerebral perfusion with moderate hypothermic lower body circulatory arrest with that of standard cardiac surgery.Material and Methods: Thirty-six consecutive patients who underwent selective antegrade cerebral perfusion with moderately hypothermic lower body circulatory arrest at 28°C (study group) for aneurysms of the ascending aorta were prospectively compared with 36 patients who underwent standard cardiac surgery (control group) with conventional cardiopulmonary bypass. Nitric oxide, asymmetric dimethylarginine, hydrogen sulfide and total antioxidant capacity status and lactate levels in blood specimens obtained from the vena cava inferior were studied. Clinical results and biochemical parameters were evaluated.Results: Biomarkers related to endothelial function were found to be similar between the groups except for asymmetric dimethylarginine. The asymmetric dimethylarginine levels were lower, while lactate levels were significantly higher compared to the control group. When the patients with coronary artery disease were excluded from the analysis to rule out the predominance of coronary artery disease patients in one group as a confounding factor, the asymmetric dimethylarginine levels were found to be similar between the two subgroups.Conclusion: Low plasma levels of asymmetric dimethylarginine in the study group may have a protective role in endothelial nitric oxide synthesis. When patients with coronary artery disease were excluded from both group, biomarkers related to endothelial function were similar in both groups. We consider that endothelial functions are not affected adversely during short periods of moderately hypothermic lower body circulatory arrest.

An increasing number of patients have required cardiac reoperations in recent decades, and this trend is expected to continue. Hence, re-sternotomy is and will be a common practice in high-volume centres. Re-sternotomy in complex aortic reinterventions carries a high risk of injuring major vascular and heart structures. To avoid catastrophic injuries, preoperative planning and case individualization are essential to minimize complications. Designing a safe and tailored strategy for each patient is believed to have an impact on postoperative outcomes. The arterial cannulation site, the need for hypothermia, left ventricle decompression and the use of an aortic occlusion balloon catheter are some of the preoperative decisions that must be made on a case-by-case basis to ensure adequate brain and visceral perfusion and to minimize major bleeding and circulatory interruption in case of re-entry injury., (© The Author 2024. Published by MMCTS on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Open in new tab Download slide Open in new tab Download slide OBJECTIVES The risk of brain injury following surgery for type A aortic dissection (TAAD) remains substantial and no consensus has still been reached on which neuroprotective technique should be preferred. We aimed to investigate the association between neuroprotective strategies and clinical outcomes following TAAD repair. METHODS Using the UK National Adult Cardiac Surgical Audit, we identified 1929 patients undergoing surgery for TAAD (2011–2018). Deep hypothermic circulatory arrest (DHCA) only, unilateral (uACP), bilateral antegrade cerebral perfusion (bACP) and retrograde cerebral perfusion were used in 830, 117, 760 and 222 patients, respectively. The primary end point was a composite of death and/or cerebrovascular accident (CVA). Generalized linear mixed model was used to adjust the effect of neuroprotective strategies for other confounders. RESULTS The use of bACP was associated with longer circulatory arrest (CA) compared to other strategies. There was a trend towards lower incidence of death and/or CVA using uACP only for shorter CA. In particular, primary end point rate was 27.7% overall and 26.5%, 12.5%, 28.0% and 22.9% for CA <30 min and 28.6%, 30.4%, 33.3% and 33.0% for CA ≥30 min with DHCA only, uACP, bACP and retrograde cerebral perfusion, respectively. The use of DHCA only was associated with five-fold [odds ratio (OR) 5.35, 95% confidence interval (CI) 1.36–21.02] and two-fold (OR 1.77, 95% CI 1.01–3.09) increased risk of death and/or CVA compared to uACP and bACP, respectively, but the effect of uACP was significantly associated with CA duration (hazard ratio 0.97, 95% CI 0.94–0.99; P  = 0.04). CONCLUSIONS In TAAD repair, the use of uACP and bACP was associated with a lower adjusted risk of death and/or CVA when compared to DHCA. uACP can offer some advantage but only for a shorter CA duration. [ABSTRACT FROM AUTHOR]

For type A aortic dissection (TAAD), antegrade cerebral perfusion (ACP) was proposed as a more physiological method than retrograde cerebral perfusion (RCP) for intra-operative brain protection, but it is still debatable whether antegrade cerebral perfusion (ACP) or retrograde cerebral perfusion (RCP) is related to the better clinical outcome. The present study was undertaken to compare the results in our patients receiving surgery for TAAD with ACP or RCP. The primary aim of this study was focused on the incidence of and the factors associated with surgical mortality, post-operative neurological outcomes and long-term survival. From February 2001 to March 2019, there were 223 consecutive patients with TAAD treated surgically at our hospital. The median age at presentation was 56 years (range 29–88 years) and 70 patients (31.4%) over 65 years of age. There were 168 patients treated with RCP and 55 patients treated with ACP. The primary endpoints were surgical mortality and neurological outcome. Propensity score matching was used to compare the treatment results of surgeries with RCP or ACP. The long-term survival was also analyzed. The overall in-hospital mortality rate and the overall 30-day mortality rate were 15.6% and 14.3% respectively. For the patients without pre-operative shock (n = 184), the in-hospital mortality rate was 10.3% and the 30-day mortality rate was 8.7% and higher long-term survival rates (88.3% for 5 years, 86.5% for 10 years, 86.5% for 15 years) were documented for this patient group. There was no significant difference on the surgical mortality between the ACP group and the RCP group. In the entire cohort, there were 23 patients (10.3%) who suffered from post-operative neurological deficits (PND) and there were less PND for the patients with RCP than the patients with ACP (7.7% vs 18.1%, p = 0.027). After propensity score matching, there was still higher incidence of PND in the ACP group than in the RCP group but without statistical significance (18.5% vs 11.1%, p = 0.279). Aortic surgery carries high risk for the patients with TAAD and PND is not an unusual post-operative morbidity. In our series, pre-operative shock, pre-operative CPR, CRI, past history with CAD are related to higher surgical mortality. The younger patients (<65 years old) without pre-operative shock got better surgical outcome and long-term survival. RCP could provide acceptable cerebral protection during aortic surgery for the TAAD patients. Old age, pre-operative shock, CRI and past history of CAD are independent risk factors for long-term survival. [ABSTRACT FROM AUTHOR]

Background: Cardiopulmonary bypass (CPB) may lead to tissue hypoxia, inflammatory response, and risk for acute kidney injury (AKI). We evaluated the prevalence of AKI and inflammatory response in neonates undergoing heart surgery requiring CPB with or without antegrade cerebral perfusion (ACP).Methods: Forty neonates were enrolled. The patients were divided into two groups depending on the use of ACP. AKI was classified based on the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Inflammatory response was measured using plasma concentrations of interleukins 6 (IL-6) and 10 (IL-10), white blood cell count (WBC), and C-reactive protein (CRP).Results: Eight patients (20%) experienced AKI: five (29%) in the ACP group and three (13%) in the non-ACP group (P = 0.25). Postoperative peak plasma creatinine and urine neutrophil gelatinase-associated lipocalin were significantly higher in the ACP group than in the non-ACP group [46.0 (35.0-60.5) vs 37.5 (33.0-42.5), P = 0.044 and 118.0 (55.4-223.7) vs 29.8 (8.1-109.2), P = 0.02, respectively]. Four patients in the ACP group and one in the non-ACP group required peritoneal dialysis (P = 0.003). Postoperative plasma IL-6, IL-10, and CRP increased significantly in both groups. There were no significant differences between the ACP and non-ACP groups in any of the inflammatory parameters measured.Conclusions: No significant difference in the AKI occurrence or inflammatory response related to CPB modality could be found. In our study population, inflammation was not the key factor leading to AKI. Due to the limited number of patients, these findings should be interpreted with caution. [ABSTRACT FROM AUTHOR]

Background: Wilms' tumor is the most common pediatric renal tumor. Almost half of all cases have involvement of the inferior vena cava, which must be addressed at the time of surgical excision. Further extension into the right atrium may pose an immediate vital risk and necessitates special operative techniques that employ cardiopulmonary bypass. Case Report: We report the case of a child with a left Wilms' tumor with inferior caval and right atrial involvement, which led to significant hemodynamic compromise and urgent surgery. A left nephrectomy and cavoatrial thrombectomy were performed via a sterno-laparotomy. Our strategy employed moderate hypothermic circulatory arrest at 26°C and antegrade cerebral perfusion in order to improve visualization and ensure complete thrombectomy and protection of the abdominal organs. Conclusion: This case emphasizes the advantages of moderate hypothermic circulatory arrest compared to deep hypothermic circulatory arrest and normothemic cardiopulmonary bypass. [ABSTRACT FROM AUTHOR]

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.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.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.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. [ABSTRACT FROM AUTHOR]

Introduction: Adequate cerebral protection for aortic reoperation is challenging and optimal technique is still controversial.Case Report: We report a hybrid cannulation approach to achieve safe cerebral protection during circulatory arrest to repair an aortic root pseudoaneurysm.Conclusion: A multidisciplinary approach combining conventional techniques and interventional expertise could be considered in complex aortic scenario. [ABSTRACT FROM AUTHOR]

Abstract Background During total aortic arch replacement surgery (TARS) for patients with acute type A aortic dissection, the organs in the lower body, such as the viscera and spinal cord, are at risk of ischemia even when antegrade cerebral perfusion (ACP) is performed. Combining ACP with retrograde inferior vena caval perfusion (RIVP) during TARS may improve outcomes by providing the lower body with oxygenated blood. Methods This study is designed as a multicenter, computer-generated, randomized controlled, assessor-blind, parallel-group study with a superiority framework in patients scheduled for TARS. A total of 636 patients will be randomized on a 1:1 basis to a moderate hypothermia circulatory arrest (MHCA) group, which will receive selective ACP with moderate hypothermia during TARS; or to an RIVP group, which will receive the combination of RIVP and selective ACP under moderate hypothermia during TARS. The primary outcome will be a composite of early mortality and major complications, including paraplegia, postoperative renal failure, severe liver dysfunction, and gastrointestinal complications. All patients will be analyzed according to the intention-to-treat protocol. Discussion This study aims to assess whether RIVP combined with ACP leads to superior outcomes than ACP alone for patients undergoing TARS under moderate hypothermia. This study seeks to provide high-quality evidence for RIVP to be used in patients with acute type A aortic dissection undergoing TARS. Trial registration Clinicaltrials.gov, ID: NCT03607786. Registered on 30 July 2018.

Objectives: Antegrade cerebral perfusion (ACP) under moderate hypothermic circulatory arrest is used during total aortic arch replacement surgery (TARS) in patients with acute type A aortic dissection, but it is associated with high mortality and morbidity. We hypothesized that combining ACP with retrograde inferior vena caval perfusion (RIVP) improves outcomes.Methods: This pilot study was prospective, randomized, controlled and assessor-blinded. Patients scheduled for TARS were randomly treated with either ACP or RIVP + ACP. The primary outcome was a composite of mortality and major complications including paraplegia, postoperative renal failure, severe liver dysfunction, and gastrointestinal complications. Secondary outcomes included neurological complications, length of intubation and requirement of blood products.Results: A total of 76 patients were recruited (n = 38 per group). Primary outcome occurred in 23 patients (61%) in the ACP group and 16 (42%) in the RIVP + ACP group (OR: 0.60, 95% CI: 0.21-1.62; p = 0.31). There was a lower incidence of transient neurological deficits in the RIVP + ACP group (26% vs. 58%, OR: 0.26; 95% CI: 0.10-0.67,p = 0.006;). The RIVP + ACP group underwent shorter intubation (25 vs 47 h, p = 0.022) and required fewer blood products (red cells, 3.8 units vs 6.5 units, p = 0.047; platelet: 2.0 units vs 2.0 units, p = 0.023) compared with the ACP group.Conclusions: RIVP + ACP may be associated with lower incidence of transient neurological deficits, shorter intubation and less blood transfusion requirement than ACP alone during TARS. Multi-center, randomized trials with larger samples are required to determine whether RIVP + ACP is associated with lower rates of mortality and major complications.Trial Registration: Pilot study of a RCT registered in clinicaltrials.gov (NCT03607786), Registered 30 July, 2018-Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03607786 . [ABSTRACT FROM AUTHOR]

Background: We designed a prospective randomized clinical study to compare unilateral and bilateral antegrade cerebral perfusion (ACP) under moderate hypethermia in open distal aortic hemiarch replacement in ascending aortic aneurysm. Methods: Forty‐two patients were prospectively randomized into two groups; unilateral ACP to Group 1 and bilateral ACP to Group 2. Inclusion criteria were pathological aortic aneurysm in the ascending aorta and/or aortic arch, elective operation, normal preoperative carotid Doppler ultrasonography, and nonexistence of preoperative neurological event. Patients were evaluated with preoperative and postoperative biochemical blood analysis, magnetic resonance imaging (MRI), and neurological disorders. The primary endpoints were permanent neurological disorder and death. Results: There were 21 patients in each group. Mean age was 56.57 ± 10.06 years in Group 1 and 50.95 ± 15.64 years in Group 2 (p =.170). No significant difference was found according to demographic data. ACP times were significantly higher in bilateral ACP (Group 1: 12.62 ± 5.04 min, Group 2: 18.23 ± 9.04 min, p =.018) whereas cross‐clamp time and cardiopulmonary bypass times were not (p =.693 and p =.584 sequentially). Transient neurological disorder was found in seven patients in Group 1 and in 4 patients in Group 2 (p =.484). Postoperative MRI revealed new milimetric ischemic zones in three patients in Group 1 but none in Group 2. No permanent neurological disorder or mortality was seen. Conclusion: The present randomized clinical prospective study could not prove the superiority of one of the technique in cerebral protection probably because, our overall ACP time was too short. [ABSTRACT FROM AUTHOR]

We aimed to compare the safety and efficacy of 3 perfusion methods primarily used in aortic arch reconstruction in infants, namely, deep hypothermic circulatory arrest, selective antegrade cerebral perfusion, and double arterial cannulation. Forty-five infants with aortic arch obstruction and biventricular anatomy were enrolled in this pilot prospective study (ClinicalTrials.gov registration number: NCT02835703). Patients were randomly assigned into 3 groups according to the perfusion strategy (deep hypothermic circulatory arrest, n = 15; selective antegrade cerebral perfusion, n = 15; double arterial cannulation, n = 15). The primary composite endpoint was the incidence of adverse events in the early postoperative period (acute kidney injury [KDIGO criteria], new brain magnetic resonance imaging (MRI) findings, and in-hospital mortality). The secondary endpoints were intensive care unit length of stay, vasoactive-inotropic score index, and cardiopulmonary bypass duration. All patients underwent aortic arch reconstruction under cardiopulmonary bypass and were monitored with near-infrared spectroscopy during surgery. No significant differences in the baseline characteristics and cardiopulmonary bypass duration were observed among the groups. The incidence of unfavorable events was lower in the double arterial cannulation group (P = 0.041). Acute kidney injury was observed in 8, 6, and 5 patients from the deep hypothermic circulatory arrest, selective antegrade cerebral perfusion, and double arterial cannulation groups, respectively (P = 0.64). Twelve patients from the deep hypothermic circulatory arrest group had new brain MRI findings (P = 0.019). There were 5 in-hospital deaths with no significant difference among the groups (P = 0.70). The "head" and "lumbar" values on near-infrared spectroscopy during aortic arch reconstruction were significantly higher in the selective antegrade cerebral perfusion and double arterial cannulation groups than in the deep hypothermic circulatory arrest group. Patients in the double arterial cannulation group had a significantly lower vasoactive-inotropic score index 24 hours postoperatively than the deep hypothermic circulatory arrest group (P = 0.03). Vasoactive-inotropic score index >12 was found to be a risk factor for acute kidney injury and early mortality. Continuous regional perfusion during aortic arch reconstruction decreases the risk of new brain MRI findings in infants and the need for postoperative inotropic support. Although values of near-infrared spectroscopy during the procedure were significantly higher with continuous perfusion strategies, these methods do not reduce the acute kidney injury incidence compared to that with deep hypothermic circulatory arrest. Double arterial cannulation significantly reduces the need for inotropic support. [ABSTRACT FROM AUTHOR]

This study examines postoperative morbidity and mortality and long-term survival after total arch replacement (TAR) using deep to moderate hypothermic circulatory arrest (HCA), antegrade cerebral perfusion (ACP), and the Y-graft. Seventy-five patients underwent TAR with the Y graft. Deep to moderate HCA was initiated at 18-22°C. ACP was either initiated immediately (early ACP) or after the distal anastomosis was performed (late ACP). The arch vessels were then serially anastomosed to the individual limbs of the Y-graft. The median age was 66 years (range = 32-82). Etiology of aneurysmal dilatation included 20 (27%) patients with medial degenerations, 25 (33%) with chronic dissections, 14 (19%) with acute dissections, 9 (12%) with atherosclerosis and 2 (3%) with Marfan syndrome. In-hospital mortality was 5%. Neurologic complications occurred in 8 (11%) patients; 2 (3%) had strokes and 6 (8%) had transient neurologic deficits. Patients undergoing TAR with moderate hypothermia had a significantly higher incidence of new-onset renal insufficiency (3 [23%] vs [0%], P < 0.001) and TND (3 (23%) vs 3 (5%), P = 0.028) than the profound and deep hypothermia cohort. Excluding the 1 patient who died intraoperatively, 89% (95%CI: 79-94%) were alive at 1 year, 78% at 5 years (95%CI: 66-86%), and 73% at 10 years (95%CI: 59-82%). The combination of deep to moderate HCA, ACP, and the Y-graft is a safe and reproducible technique. Further inquiry is needed to assess if early ACP provides superior clinical outcomes. [ABSTRACT FROM AUTHOR]

We aimed to monitor regional oxygen saturation levels using near-infrared spectroscopy in patients undergoing total aortic arch replacement and to determine the range of collateral flow via antegrade cerebral perfusion to the spinal cord during lower body circulatory arrest. Eighteen consecutive patients undergoing total aortic arch replacement in our hospital were prospectively enrolled. Optodes of near-infrared spectroscopy were attached to the skin at the right and left forehead, and above the paravertebral muscles at the level of the third (T3) and tenth (T10) thoracic vertebra. Within- and between-group differences were compared using mixed-effect model repeated-measures analysis. Regional oxygen saturation levels, which had been rapidly declining immediately after circulatory arrest at a tympanic temperature of <25°C and a core temperature of <30°C, showed a rapid increase at the forehead with the initiation of antegrade cerebral perfusion (total flow rate 0.81 ± 0.08 L/min, perfusion pressure 37 ± 6 mm Hg, temperature 25°C). Saturation levels remained only partially elevated at the upper thoracic level (T3) and continued to decline without showing signs of recovery at the lower thoracic level (T10). Antegrade cerebral perfusion partially perfused the upper thoracic cord via collateral circulation from vertebral arteries through an anterior spinal artery, but it did not reach the lower thoracic cord sufficiently to change the oxygenation level. Cooling is a more important means of protection for the lower spinal cord during lower body circulatory arrest than is antegrade cerebral perfusion. [ABSTRACT FROM AUTHOR]

We present a case of antegrade cerebral perfusion based on a circuit with a centrifugal pump for general open-heart surgery to achieving cerebral protection during a challenging hybrid aortic arch repair. [ABSTRACT FROM AUTHOR]

Keywords: Cerebral protection; Aortic arch surgery; Antegrade cerebral perfusion EN Cerebral protection Aortic arch surgery Antegrade cerebral perfusion 1 2 2 07/04/23 20230601 NES 230601 Lack or shortage of oxygen delivery leads to organ damage. Cerebral oxygen delivery is a function of cerebral blood flow (CBF) and blood oxygen content, whereby the CBF is dependent on cerebral perfusion pressure and inversely proportional to cerebrovascular resistance. Perioperative cerebral perfusion in aortic arch surgery: a potential link with neurological outcome. [Extracted from the article]

Objective To determine which of antegrade and retrograde cerebral perfusion (ACP and RCP) surpasses for a reduction in postoperative incidence of neurological dysfunction and all-cause death in thoracic aortic surgery, we performed a meta-analysis of contemporary comparative studies. Methods MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched from January 2010 to June 2017. For each study, data regarding the endpoints in both the ACP and RCP groups were used to generate odds ratios (ORs) and 95% confidence intervals (CIs). Study-specific estimates were combined using inverse variance-weighted averages of logarithmic ORs in the fixed-effect model. Results We identified and included 19 eligible studies with a total of 15,365 patients undergoing thoracic aortic surgery by means of ACP (a total of 7,675 patients) or RCP (a total of 7,690 patients). Pooled analysis demonstrated no statistically significant differences in postoperative incidence of stoke (17 studies enrolling a total of 9,421 patients; OR, 0.92; 95% CI, 0.79–1.08; p = 0.32) and mortality (16 studies including a total of 14,452 patients; OR, 1.07; 95% CI, 0.90–1.26; p = 0.46) between ACP and RCP, whereas a trend toward a significant reduction in incidence of temporary neurological dysfunction (TND) for ACP (12 studies enrolling a total of 7922 patients; OR, 0.85; 95% CI, 0.69–1.04; p = 0.12) was found. Conclusion In thoracic aortic surgery, postoperative incidence of stroke and mortality was similar between ACP and RCP, whereas a trend toward a reduction of TND incidence existed in ACP. [ABSTRACT FROM AUTHOR]

Background: Techniques for the surgical correction of aortic aneurysms have steadily improved since the first described successful repair, Despite these improvements, postoperative neurological complications remain a major factor in determining an adverse outcome. Complex aortic arch reconstruction in neonates and children is performed typically under deep hypothermic circulatory arrest. Aim: The study aimed at examining the effect of clinical impact, particularly neurologic complications, of deep hypothermic circulatory arrest in pediatric arch surgery and to summarize the early outcomes. Patients and method: One-handed and fourteen underwent full-term babies were enrolled in the present study. The maximum age was 20 weeks, arch surgery included Norwood, arch reconstruction for hypoplastic arch and interrupted aortic arch. Healthy neurological status preoperative was included between January 2011 and October 2015. The medical records were reviewed for preoperative diagnosis of patients which included age at the time of operation, sex and diagnosis of the patients. Operative details including type of the operation, duration of cross-clamp and deep hypothermic circulatory arrest timing were documented. The deep hypothermic circulatory arrest was conducted at 20 °C. Postoperative outcomes, neurological complications including seizers, cerebral infarct, and duration of hospital stay were recorded. Results: The study noted that the incidence of postoperative complications such as seizure & bleeding was markedly 5.3%& 1.8% of the studied pediatric patients. Conclusion: The results concluded that the aortic arch reconstruction with Antegrade cerebral perfusion during the deep hypothermic circulatory arrest was accompanied by a lower risk of neurological complications. Recommendations: Long-term neurodevelopmental follow-up of these children is required to evaluate the late outcomes of Antegrade cerebral perfusion. [ABSTRACT FROM AUTHOR]

Systemic hypothermia with bilateral antegrade selective cerebral perfusion (ASCP) is the preferred cerebral protective strategy for type A aortic dissection surgery. The optimal ASCP flow rate remains uncertain and the target flow cannot always be reached due to pressure limitations. The aim of this study was to assess the correlation between ASCP flow and regional cerebral oxygen saturation (rSO2).A retrospective analysis was performed on 140 patients with acute type A aortic dissection who underwent surgery with moderate hypothermic circulatory arrest and bilateral ASCP between 2015 and 2021. Pearson correlation analysis was performed between ASCP flow and rSO2.The median circulatory arrest duration was 46.5 (IQR:37.0-61.0) minutes. There was no significant correlation between ASCP flow and rSO2 for both the right (r = -.02, p = .851), and the left hemisphere (r = - .04, p = .618). The rSO2 values for ten patients who received > 10 mL/kg/min flow did not differ significantly from 130 patients who received 10 mL/kg/min or less for both the left hemisphere (p = .135), and the right hemisphere (p = .318). The ASCP flow was 5.1 (IQR:5.0- 6.5) mL/kg/min in five patients with, and 7.2 (IQR:5.8-8.3) mL/kg/min in 135 patients without a watershed infarction (p = .098).There was no correlation between ASCP flow rate and rSO2 in patients with acute type A aortic dissection. Furthermore, ASCP flow below 10 mL/kg/min was not associated with a reduction in rSO2. Definitive associations between ASCP flow and neurological outcome after type A aortic dissection surgery need further investigation. [ABSTRACT FROM AUTHOR]