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Soon after that, Cooley and DeBakey, extended this technique for acute aortic dissection in order to provide a bloodless surgical field, excision of the torn aortic wall, and repair of the aortic arch. Kouchoukos started to use cardiopulmonary bypass with deep hypothermia and circulatory arrest in descending and thoracoabdominal aneurysm repair for medullar protection.

In the late 1980s deep hypothermic circulatory arrest had large acceptance as the standard approach for arch surgery. In spite of meticulous cooling and rewarming techniques, with careful monitoring, a duration of hypothermic total circulatory over 25 min has been shown to produce at least symptoms characterized as temporary neurologic dysfunction (obtundation, disorientation), especially in elderly patients (R. Griepp) [24].

In addition to hypothermia and in order to reduce the low temperature with bleeding burdening postoperative evolution, it became obvious that a cerebral perfusion during total circulatory arrest, like for the arrested heart, cardioplegia, will be useful. Two methods give blood to the brain: retrograde cerebral perfusion and anterograde cerebral perfusion [25].

Retrograde Cerebral Perfusion

Retrograde cerebral perfusion was first used by Mills and Oschner for the management of massive arterial air embolism in

1980.

In 1990, Ueda and his team were the first to introduce retrograde cerebral perfusion in combination with deep hypothermia to provide retrograde perfusion and additional cooling of the brain via superior caval venae and cerebral venous system, for the aortic arch reconstruction [25–27].

Technically this procedure is very easy. After cooling the patient to 18–20°C, circulatory arrest is instituted and from bicaval venous cannulation, a superior cava cannula is used for retrograde cerebral perfusion from the arterial line of the pump, with a flow of 200 mL/min, pressure of 20 mmHg. This technique has been widely adopted during aortic arch surgery under hypothermic circulatory arrest in many centers, even in our center with quite good results, with mortality of 10% in acute aortic dissection with aortic arch repair. In Vienna this technique was introduced by E. Wolner, M. Havel, and G. Laufer in 1995 and Timisoara in 1997 with good results, mortality under 10%, and no permanent neurological disorders [28].

Retrograde blood flow through superior cava venae is between 100 and 500 mL/min, to maintain a central venous pressure between 15 and 25 mmHg, which is monitored by central venous pressure catheter, jugular bulb catheter (jugular venous saturation 95%), EEG, transcranial Doppler, or more sophisticated, near-infrared spectroscopy.

Retrograde cerebral perfusion provides a good operative field without complicated cardiopulmonary circuits. There are time limitations on safe retrograde cerebral perfusion. Ice packed around the head may avoid the effect of intracerebral temperature gradient and brain rewarming during the period of arrest. In addition, pharmacological drugs are used.

Even a Japanese team has proposed that retrograde cerebral perfusion should not exceed 60 min when sufficient flow is not present, because it is nonphysiological perfusion; retrograde cerebral perfusion later declined in favor of anterograde cerebral perfusion [29].

Anterograde Cerebral Perfusion

The next milestone in the evolution of modern aortic arch surgery was successfully introduced into clinical practice by Jean Bachet and Daniel Guilmet in Europe [30] and by Teruhisa Kazui and colleagues in Japan in 1986 [31]; anterograde selective cerebral perfusion, in combination with moderate hypothermia, significantly reduced the incidence of neurologic complications and postoperative bleeding.

For the first 100 cases between 1986 and 1993, using anterograde cerebral perfusion via innominate and left carotid artery, femoral for distal body, at the temperature of 22°C, Kazui had a 30-day mortality of 16%. After 1992, the hospital mortality decreased to 4%, 3%, and no stroke.

In 1999, Bachet using neuroprotective strategy, “cold cerebroplegia,” by using cold blood (6–12°C), and selective cerebral perfusion via the carotid arteries during circulatory arrestin moderate hypothermia (26°C), which allowed for longer operation times in more complex procedures with lower neurologic complications (one stroke) and 13% postoperative mortality.

In 2007, the Bologna (Italy) group published their results of 305 aortic arch operations utilizing the following: Group I, deep <22°C, versus group II moderate hypothermia, up to 26°C, during an average anterograde cerebral perfusion, time of up to 60 min with no differences between both groups with regard to 30-day mortality of 12.7% versus 13.8%, permanent neurologic disorder of 3.1% versus 1.7%, and temporary neurologic disorder of 7.9% versus 8.6% [32].

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Furthermore, they compared 17 patients operated on for aortic arch at 26°C and antegrade cerebral perfusion, circulatory arrest with 15 patients with coronary artery bypass in normothermia, using cerebral positron emission tomography, diffusion-weighted imaging, proton magnetic resonance spectroscopy, and cognitive functions to elucidate whether cerebral perfusion is different [33]. They concluded the efficacy of anterograde cerebral perfusion in preserving brain tissue metabolism and functions during aortic arch surgery using a multimodal protocol; the perfusion of the innominate artery and the left common carotid artery at a flow rate of 10 mL kg/1 min/1 at 26°C of nasopharyngeal temperature guaranteed an adequate blood supply to the overall brain during systemic circulatory arrest [34].

The group from Hannover, between 1999 and 2006, reported 501 aortic arch surgery operations in circulatory arrest, with moderate hypothermia, 25°C and anterograde selective cerebral perfusion, with a mortality of 11%, 6%, permanent neurologic damage of 9% and 6%, and temporary neurologic disorder of 13%, and they concluded that moderate hypothermic circulatory arrest in combination with cold selective anterograde cerebral perfusion is an adequate tool for neuroprotection during aortic surgery, but the safety of this technique is limited for patients with long intraoperative durations, advanced age, and multiple comorbidities [35].

Despite the absence of confirmative data for the safety of higher body core temperatures, more and more aortic surgery centers have started using moderate-to-mild (28–35°C) hypothermic or even normothermic body core temperatures during routine arch repair, and increasingly even for complex surgery, including acute type A aortic dissections [36].

The monitoring of aortic arch surgery during circulatory arrest tries to detect and avoid intraoperative malperfusion. The usual monitoring during HCA includes nasal and rectal temperature, oxygen saturation of the jugular venous bulb (SvO2), EEG, somatosensory-evoked potential, transcranial Doppler, and near-infrared spectroscopy [37].

Malperfusion of cerebral and visceral organs can appear at any time during surgery; it could be present even before or after surgery with very serious consequences in spite of apparently correct surgical technique [38]. However, the safe limits of prolonged distal circulatory arrest, particularly with regard to the ischemic tolerance of the viscera and the spinal cord, have not yet been clearly defined.

Distal Visceral Perfusion

We should not forget the distal aorta organs: medullar spine, kidneys, liver, and guts. Distal perfusion via the femoral artery

can be successfully used in selective cases during total aortic arch replacement to sustain spinal cord and visceral integrity at moderate hypothermia. This has been shown to reduce the incidence of end-organ complications, particularly in more extensive procedures. Some authors are cannulating the true lumen of the descending thoracic aorta with a cuffed cannula giving full-flow antegrade perfusion of the thoracoabdominal organs [39,40].

TOTAL AORTIC ARCH REPLACEMENT TECHNIQUE

History: The first total resection of the aortic arch in 1955 was by Cooley, for a large syphilitic aneurysm of the aortic arch using a temporary shunt of a 14-mm Ivalon tube to provide circulation to the carotids and distal aorta (Fig. 31.4); surface cooling was used for cerebral protection. “Total excision of the aortic arch and replacement with a custom-made Ivalon prosthesis was performed. After the reconstruction, the temporary shunt was removed. The procedure went smoothly; however, the right carotid shunt became occluded for 8 minutes before flow could be restored. The patient sustained a stroke and later died” [41].

In 1975, Cooley reported a successful four-stage complete aortic replacement in a young woman with Marfan syndrome who had aneurysmal dilatation of the entire aorta and aortic valve insufficiency (Cooley). The retrograde “pull-through” technique is the simplest, most effective method for complete replacement of the aorta yet described [9].

Open Technique for Aortic Arch Replacement

There are two classical methods of supra-aortic arch vessel reconstruction for total aortic arch replacement, in aortic arch aneurysm as well in acute and chronic dissection: inclusion technique and isolated branch anastomosis [18,42].

In the past, the first technique was the most used for vessel implantation; with an elliptical excision in the graft, “island patch technique” or inclusion technique and all the origins of aortic vessel were prepared elliptical and sutured to the prosthesis; femoral artery was the arterial inflow, deep hypothermia total circulatory arrest at 18°C, retrograde cerebral perfusion, and island technique for supra-aortic vessel reconstruction [43].

There are some disadvantages to the island patch technique [44]. First, this technique can have difficult bleeding control from the posterolateral aspect of the anastomosis, and the aortic tissue left behind can become aneurismal in time,

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FIGURE 31.4 D. Cooley, 1955, first aortic arch replacement using a temporary shunt for cerebral protection and Ivalon prosthesis for aortic arch (Cooley).

FIGURE 31.5 Total aortic arch replacement: (A) inclusion technique, (B) Isolated branch anastomosis and intraoperative view.

necessitating a second operation; this problem is most common in patients with connective tissue disorders, such as Marfan patients (Fig. 31.5)

Actually, many surgical teams have changed this technique, using axillary artery or innominate trunk cannulation, at the moderate 23–26°C circulatory arrest, antegrade cerebral perfusion via innominate artery, a special commercial aortic arch prosthesis with three or four branches that are used for separate, left carotid artery, left subclavian artery, and innominate trunk anastomosis, assuring all this time an anterograde cerebral perfusion at a flow of 10 mL/hg/min with near infrared spectroscopy cerebral oxygen (Fig. 31.6).

Antegrade cerebral perfusion during moderate circulatory arrest, possibly combined with distal aortic perfusion, should currently be considered the state of the art for transverse arch surgery.

A complex aortic root replacement, Tirone David repair, Magdi Yacoub technique, or total replacement Bentall–DeBono, associated with total arch replacement for aneurysm or dissection, are even more massive and difficult procedures. Such procedures are recommended in young patients with Marfan syndrome because of the extensive connective tissue disorders.

In conclusion, many centers still believe that, in patients with isolated arch disease, open repair remains the gold standard and is feasible even in high-risk patients with acceptable morbidity and mortality. In patients with prohibitively high risk, an alternative solution to open repair may improve outcomes [45–48].

Partial Arch Repair Technique

For saccular aneurysms that originate from the lesser arch curvature and involve less than 50% of the aortic arch, a patch repair without circulatory arrest was used even before the cardiopulmonary bypass era. The ascending aortic aneurysm that

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FIGURE 31.6 Aortic arch replacement with a four-graft prosthesis using moderate hypothermia and bilateral anterograde cerebral perfusion via axillary artery and left carotid artery (Timisoara, 2011).

FIGURE 31.7 Partial proximal aortic arch replacement in case of ascending aortic aneurysm and dissection with aortic arch extension.

extends into only the proximal portion of the arch can be repaired with a hemiarch approach by using an oblique cutting graft, to replace a portion of the lower curvature of the arch (Fig. 31.7).

Also for acute dissections type A that involve ascending aorta and extend into the aortic arch (DeBakey I or II), the hemiarch technique is often used when the rest of aortic arch intima seems to be without tears [42]. In some situations, innominate artery can be implanted using a graft tube of 8-mm diameter end to end (Fig. 31.8).

Distal aortic arch aneurysm with left subclavian artery involvement can be approached by left anterolateral thoracotomy IV intercostal space without cardiopulmonary arrest with a proximal clamp between the left common carotid artery and distal aorta, Dacron tube end to end, and left subclavian artery reimplantation.

Elephant Trunk Technique

In some specific situations when the pathology of aortic arch (aneurysm, dissection), acute or chronic, extends into descending aorta, a “technique of elephant trunk,” described by Borst, is a procedure used to facilitate staged surgery for the aortic arch and the distal aortic segments [49]. In the first step, ascending aorta and aortic arch are replaced with a Dacron graft and an extension of this prosthesis is left down into a descending aorta to make a second-stage operation easier. But the mortality still remains very high at the first operation, and another 15% mortality is added at the second step or the patients die before that.

In 1996 a combination between the classic “elephant trunk” technique, with a Dacron graft, and the endovascular stent devices was introduced on the same time, through the open aortic arch, named “frozen elephant technique”; this was done in order to avoid the second operation in selected patients, preventing morbidity and mortality of a reoperation [50].

The Hannover surgical team used three different prostheses (Chavan–Haverich, Jotec–Evita, and Thoraflex) for frozen “elephant trunk,” during 10 years, to treat aortic aneurysm, and dissection of aortic arch and descending aorta in a singlestage operation (Fig. 31.9). They reported good results.

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FIGURE 31.8 Acute aortic dissection type A with ascending aorta replacement and hemiaortic arch (Timisoara).

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FIGURE 31.9 Hannover surgical team during the last 10 years using three different graft prostheses for frozen elephant trunk operation: (A) Chavan– Haverich prosthesis, (B) Jotec–E-vita prosthesis, and (C) Thoraflex prosthesis.

A further step was done by the same Hannover team with a collapsed endoprosthesis inserted in descending aorta through open aortic arch, a collar for easy distal anastomosis, four-branched graft for aortic graft replacement, and great vessel anastomosis (Fig. 31.10).

The device was inserted successfully in 34 cases, without operative mortality but later three deaths, 12 patients with

postoperative bleeding, and no neurological permanent disorders [51].

Appropriate selection of patients with acute and chronic aortic arch and distal aneurysm and dissection, as well as consideration of the medical center’s experience, and when to do and what to choose can improve the results in this aggressive pathology [52,53].

Sun’s procedure, in 2002, tried to be more effective by using a hybrid graft, a combination between a four-branched arch

graft and a self-expanding stent graft in a single piece.

The indication is for a treatment of extensive aortic dissections or aneurysms involving the ascending aorta, aortic arch, and the descending aorta. Technically, Sun’s procedure consists of implantation of the special open stent graft into the descending aorta, total arch replacement with a four-branched vascular graft.

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FIGURE 31.10 Hybrid graft with four-branched arch graft and compacted stent for “frozen elephant trunk” technique.

For this they used a right axillary artery for arterial line, moderate hypothermia at 25°C for circulatory arrest, and a specific sequential anastomosis in order to shorten circulatory arrest, as well as early rewarming of the brain and distal organs [53].

This procedure was used worldwide in over 8000 patients in China and more than 200 patients in South American countries with very impressive early results. In a series of 1092 patients, the authors achieved an in-hospital mortality rate of 6.27% (7.98% in emergent or urgent vs. 3.98% in elective cases) [54].

The advantage of Sun’s procedure lies in its technical simplicity, as it can be deployed very easily and quickly.

Hybrid Procedure of Total Aortic Arch Replacement

Currently, the same innovative spirit is being used to repair the aortic arch with hybrid endovascular techniques without cardiopulmonary bypass, circulatory arrest and their burdening complications, to reduce mortality and morbidity, especially for older patients and complicated cases.

The arch hybrid concept is comprised of two major steps: first, debranching of the aortic arch vessels to avoid or minimize cardiopulmonary bypass, aortic cross clamp, and circulatory arrest times; and second, creation of good proximal and distal landing zones for stent implantation at the same time, anterograde or later retrograde [55].

The classification technique for hybrid arch debranching procedures is dictated by the extent of proximal and distal landing zone reconstruction required, and thus the need and extent of cardiopulmonary bypass and circulatory arrest management (Fig. 31.11).

Hybrid surgery, associated with an extra-anatomical bypass of the supra-aortic trunks without using CPB and the use of a covered stent, was first described in 1998 by Buth.

First experiences started like case reports, in difficult cases, with total rerouting of supra-aortic vessels with tubular grafts and metachronously, endovascular stent-graft placement from the distal ascending aorta up the thoracoabdominal transition [56].

However, a lot of authors use many different techniques for hybrid procedures, with cardiopulmonary bypass, but without which is the ultimate goal. Therefore such heterogeneity in the hybrid techniques may have jeopardized the comparability of the outcomes [57,58].

Also, the stent graft is evolving from the first generation, which needs a proximal landing zone over 2 cm to the next generation with a landing zone under 2 cm, smaller fenestration and better flexibility, fixation, and precurved, fenestrated endograft. Technical success, defined as the successful deployment at the intended location of the aortic arch, was achieved in 390 of the 393 treated patients. Initial success, defined as the absence of type I or III endoleaks on postoperative CT scan, was obtained in 375 (95.4%) cases. The hospital mortality rate was 1.5%, cerebrovascular accidents 1.7% [59]. These are good results.

The question of “whether hybrid procedures are as good, or better than, open ones for total repair of the aortic arch will remain unanswered” (Kouchoukos). Some reports failed to show any difference between open arch and hybrid technique results regarding mortality and neurological complications. Moreover, reintervention rates appear to be higher for hybrid procedures, compared with conventional open-arch replacement [60].

The team from Vienna stated that “The hybrid technique is not intended as a replacement of conventional aortic arch surgery. The main aim of hybrid approaches is to serve as an alternative in patients with multisegmental thoracic aortic

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FIGURE 31.11 Landing zone and aortic arch debranching before stent implantation.

pathology which would otherwise require a two-step conventional approach with arch replacement in the first step, and open descending repair in the second” [61].

A multidisciplinary team from the European societies of cardiac surgeons, cardiologists, and interventional cardiologists, monitored the tremendous increasing of hybrid techniques in order to generate an expert position regarding diagnosis, indication and applicability, limitations, and complications. They concluded that a multidisciplinary team approach in dedicated centers for aortic pathology offers the best outcomes for patients [62].

COMPLICATIONS OF AND RESULTS OF AORTIC ARCH SURGERY

Indubitably, aortic arch surgery, open technique or hybrid techniques, with or without cardiopulmonary bypass, total circulatory arrest for aneurysm or for dissection, acute or chronic, carries high risks of operative death, stroke, and a lot of complications.

It is difficult to interpret the results across these various approaches, variables of patients, previous surgeries, techniques

to use, small tricks, and specific environmental conditions of some performance centers and teams.

For this reason, the International Aortic Arch Surgery Study Group has been formed to enable multi-institutional collaboration to better explore the impact of surgical techniques on patient outcomes, using uniform definitions of events and clinical end points.

They defined 15 clinical end points of six major systems for aortic arch surgery and graded according to their clinical manifestations, time course and severity, and treatment provided. These six major systems include neurological, cardiovascular, respiratory, renal, gastrointestinal, and other systems.

Such classification promotes consistent reporting, uniform definitions, and a reliable systematic appraisal of arch surgery. This will be the first, and perhaps most important, step in evaluating the progress achieved in aortic arch surgery over the past 30 years and will help guide future avenues of reporting and research [63].

RESULTS OF AORTIC ARCH SURGERY

Regarding the heterogeneous results of aortic arch surgery, an excellent paper with more than1200 consecutive patients who underwent aortic arch repair with reimplantation of at least one supra-aortic artery between 2004 and 2013 were collected from 11 European cardiovascular centers, and retrospective statistical examination was performed (Urbanski).

The most frequent indications for aortic arch surgery were aortic arch aneurysm (70%), followed by chronic dissection (23%), and other pathologies (trauma, iatrogenic; 7%).

When aortic arch repair was involved, all three major arteries were named, total (more than 75%), two arch artery reim-

plantations (12%), subtotal or one arch artery, partial.

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The patients’ characteristics as well as the surgical techniques, surgical access (full sternotomy, partial sternotomy, bilateral thoracotomy) including the method of cannulation, perfusion and protection, varied considerably among the surgical centers participating in the study.

Arterial cannulation was also used in accordance with the preferences of the respective center; the right axillary artery was the most frequently used arterial cannulation site (37%), followed by direct aortic (25%), common carotid artery (14%), innominate artery (12%), and femoral artery (10%).

The reported cerebral protection strategies comprised mainly bilateral (63%) or unilateral (31%) anterograde cerebral

perfusion and deep total circulatory arrest (6%).

The in-hospital and 30-day mortality rates were 11.4%, ranging between 1.7% and 19.0% in the surgical centers. Late survival at 5 and 8 years was 72% and 64%. They identified like risk factor of mortality, surgical center, patient’s age, number of previous surgeries with sternotomy and concomitant procedures.

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