Boston - American Association for Thoracic Surgery

AMERICAN ASSOCIATION FOR THORACIC SURGERYT2. Use of Subclavian-Carotid Bypass and Thoracic StentGrafting to Minimize Cerebral Ischemia in Total AorticArch ReconstructionsSteve Xydas, 1 Benjamin Wei, 2 Hiroo Takayama, 1 Mark J. Russo, 1Craig R. Smith, 1* Matthew D. Bacchetta, 1 Allan Stewart 11. NY Presbyterian Hospital-Columbia, Division of Cardiothoracic Surgery,New York, NY, USA; 2. NY Presbyterian Hospital-Columbia, Department ofSurgery, New York, NY, USAInvited Discussant: John A. KernOBJECTIVE: Total aortic arch replacement (TAAR) typically requires either aperiod of hypothermic circulatory arrest (HCA) and/or the use of antegrade selectivecerebral perfusion (SCP), carrying the risks of cerebral ischemia. We recentlyintroduced the use of left subclavian-carotid bypass (SCB) prior to TAAR withstaged thoracic stent grafting to achieve total arch reconstruction with relativelyshort periods of SCP. We compared our institutional experience of TAAR with andwithout SCB.METHODS: From July 2004 to August 2008, 329 patients at our institutionunderwent ascending aorta or arch replacements. Of these, 34 patients (64% male,36% female; mean age 66 years) underwent TAAR. TAAR was performed withcannulation of the right axillary artery to establish SCP after cooling to 28 degreesC and/or HCA at 18 degrees C. In 2008, we began performing left SCB prior to adebranching procedure of the aortic arch involving use of a bifurcated aortic graftwith aorta to innominate and aorta to left carotid artery bypass. These patientsthen underwent staged thoracic aortic stenting with deployment into the aorticgraft to complete arch reconstruction. 28 patients received TAAR without left SCB(Group I). 6 patients received TAAR with left SCB and aortic stent grafting (Group II).WEDNESDAYMorningRESULTS: Patient characteristics are shown in Table 1. The mean duration of SCBtime in Group I was 34 minutes, compared to 16 minutes in Group II (p = 0.007).50% of the patients in Group I required HCA, compared to 0% in group II. Themean cardiopulmonary bypass (218 min vs 154 min, p = 0.03) and aortic crossclamptimes (109 min vs 76 min, p = 0.04) were longer in Group I than Group II.The incidence of neurological complications, defined as stroke or spinal cordischemia within 48 hours of surgery, was 18% in Group I (5/28), compared to 0%(0/6) in Group II (p = 0.28). There were no significant differences in the mortalityrate or the length of ICU or hospital stay between Groups I and II.CONCLUSION: Left SCB prior to TAAR with staged thoracic stent grafting toachieve total arch reconstruction was associated with a significant decrease in theduration of SCP and eliminated the need for HCA. This technique may prove todecrease the risk of neurological complications associated with TAAR and providea viable hybrid approach to patients with aortic arch aneurysms.* AATS Member199