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ISSN (On-line): 1678-9741 Impact Factor: 0.809 Increase of 20% over the last evaluation
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Volume 33 Number 2, March - April, 2018

ORIGINAL ARTICLE

DOI: http://dx.doi.org/10.21470/1678-9741-2017-0123

Predictors of Outcomes after Correction of Acute Type A Aortic Dissection under Moderate Hypothermic Circulatory Arrest and Antegrade Cerebral Perfusion

George SamanidisI; Charalampos KatselisI; Constantinos ContrafourisI; Georgios GeorgiopoulosII; Ioannis KriarasIII; Theofani AntoniouIV; Konstantinos PerreasI

IFirst Department of Adult Cardiac Surgery, Onassis Cardiac Surgery Center, Athens, Greece.
IIFirst Department of Cardiology, Hippokration Hospital, University of Athens, Athens, Greece.
IIIDepartment of Cardiac Surgery Intensive Care Unit, Onassis Cardiac Surgery Center, Athens, Greece.
IVDepartment of Anesthesiology, Onassis Cardiac Surgery Center, Athens, Greece.

This study was carried out Onasseio Kardioxeirourgiko Kedro - First Department of Adult Cardiac Surgery, Athens, Greece.

Correspondence To:
George Samanidis
Onassis Cardiac Surgery Center
356 Syggrou Av., 17674 – Athens, Greece
E-mail: gsamanidis@yahoo.gr

ABSTRACT
Introduction: Hypothermic circulatory arrest is widely used for correction of acute type A aortic dissection pathology. We present our experience of 45 consecutive patients operated in our unit with bilateral antegrade cerebral perfusion and moderate hypothermic circulatory arrest.
Methods: Between January 2011 and April 2015, 45 consecutive patients were admitted for acute type A aortic dissection and operated emergently under moderate hypothermic circulatory arrest and bilateral antegrade cerebral perfusion.
Results: Mean age was 58±11.4 years old. Median circulatory arrest time was 41.5 (30-54) minutes while the 30-day mortality and postoperative permanent neurological deficits rates were 6.7% and 13.3%, respectively. Unadjusted analysis revealed that the factors associated with 30-day mortality were: preoperative hemodynamic instability (OR: 14.8, 95% CI: 2.41, 90.6, P=0.004); and postoperative requirement for open sternum management (OR: 5.0, 95% CI: 1.041, 24.02, P=0.044) while preoperative hemodynamic instability (OR: 8.8, 95% CI: 1.41, 54.9, P=0.02) and postoperative sepsis or multiple organ dysfunction (OR: 13.6, 95% CI: 2.1, 89.9, P=0.007) were correlated with neurological dysfunction. By multivariable logistic regression analysis, postoperative sepsis and multiple organ dysfunction independently predicted (OR: 15.9, 95% CI: 1.05, 96.4, P=0.045) the incidence of severe postoperative neurological complication. During median follow-up of 6 (2-12) months, the survival rate was 86.7%.
Conclusion: Bilateral antegrade cerebral perfusion and direct carotid perfusion for cardiopulmonary bypass, in the surgical treatment for correction of acute aortic dissection type A, is a valuable technique with low 30-day mortality rate. However, postoperative severe neurological dysfunctions remain an issue that warrants further research.

Keywords Cerebrovascular circulation. Hypothermia, Induced/Methods. Perfusion/Methods. Aneurysm, dissecting/surgery. Aortic aneurysm/surgery

ABBREVIATIONS AND ACRONYMS

AAD = Acute type A aortic dissection

ACP = Antegrade cerebral perfusion

AF = Atrial fibrillation

BACP = Bilateral antegrade cerebral perfusion

CA = Circulatory arrest

CCA = Common carotid artery

CNS = Central nervous system

CPB = Cardiopulmonary bypass

CT = Computed tomography

DHCA = Deep hypothermic circulatory arrest

DHCA/UACP or BACP = Deep hypothermic circulatory arrest with unilateral or bilateral cerebral perfusion

HTK = Histidine-tryptophan-ketoglutarate

ICU = Intensive care unit

MHCA/BACP = Moderate hypothermic circulatory arrest and bilateral antegrade cerebral perfusion

MHCA/UACP or BACP = Moderate hypothermic circulatory arrest with unilateral or bilateral cerebral perfusion

PND = Permanent neurological dysfunctions

RCP = Retrograde cerebral perfusion

TIA = Transient ischemic attack

TND = Temporary neurological dysfunctions

UACP = Unilateral antegrade cerebral perfusion

INTRODUCTION

Hypothermic circulatory arrest (CA) is widely used for correction of acute type A aortic dissection (AAD). In an attempt to establish a bloodless surgical field and ameliorate brain protection, which is more vulnerable in this case, a variety of techniques for cardiopulmonary bypass (CPB) and cerebral perfusion during CA have been suggested over the years[1-3].

We present our experience of 45 consecutive patients who underwent AAD correction with moderate hypothermic CA and bilateral antegrade cerebral perfusion (MHCA/BACP) via the common carotid arteries.

METHODS

Study Population

Between January 2011 and April 2015, 45 consecutive patients underwent an emergency operation for type A AAD (with or without aortic root and valve involvement) with MHCA/BACP. The preoperative diagnosis was established with computed tomography (CT) of thoracic and abdominal aorta, including aortic arch branches. All preoperative, perioperative and postoperative data were recorded.

Two patients were operated with preoperative minor neurological dysfunction [transient ischemic attack (TIA)].

This study was carried out according to the principles outlined in the Declaration of Helsinki. It is a retrospective analysis approved by the hospital's institutional ethics committee (546/30-04-2015) and all patients gave their informed consent prior to the operation.

Surgical Technique

All patients underwent an emergency surgical correction of AAD within 24 hours of admission. The briefly applied surgical technique consisted of standard median sternotomy and CPB via: 1) right or left carotid artery (connecting through a 10-mm synthetic graft)/bicaval cannulation in 42 patients and 2) femoral artery/bicaval cannulation in 3 patients. Gradual cooling of the body (1°C/5 min) and alpha-stat (pH management) was utilized. Myocardial arrest and protection was achieved with retrograde delivery of histidine-tryptophan-ketoglutarate (HTK) crystalloid solution (Custodiol®).

Once CPB was instituted, the aortic cross-clamp was applied, the cooling initiated and, with the heart stopped, correction of the proximal ascending aorta ± aortic root was undertaken, including any other required correction.

When bladder temperature reached ≈ 23°C, the head was packed in ice and the circulation, except for the carotids, was interrupted. CPB and antegrade cerebral perfusion (ACP) were achieved using synthetic graft (10 mm) in the right or left common carotid artery (CCA) and selective cannulation of the contralateral CCA. Where CBP was established with femoral artery/bicaval cannulation. ACP was performed with selective cannulation of both CCA. The ACP blood flow was 10 mL/kg/min (perfusion pressure around 50-70 mmHg, blood temperature ≈20°C). The distal anastomosis in the proximal or middle aortic arch was performed. After heart de-airing and gradual rewarming, the patients were weaned from CPB.

Degree of Postoperative Neurological Complications

Major postoperative neurological dysfunctions were evaluated by a neurologist and serial brain CT. In addition, neurological dysfunctions were divided in the four sub-groups: 1) no neurological dysfunction; 2) temporary neurological dysfunctions (TND): TIA, delirium and disorientation (<24 hours after extubation); 3) permanent neurological dysfunctions (PND): hemiplegia or paraplegia (>48 hours) that persisted after discharge at home; and 4) heavy neurological deficits (diffuse and irreversible brain damage or coma). Patients discharged were followed-up in regular intervals in outpatients' clinic with echocardiography and, if required, chest and brain CT scan.

Statistical Analysis

Continuous variables are presented as means ± SD and categorical variables are expressed as percentages. Not normally distributed continuous variables are presented as medians (interquartile range). Univariate binary logistic regression analysis was performed to identify factors associated with postoperative mortality and/or neurological complications within 30 days from surgery. For 30-day mortality, the hospital length of stay and the presence of postoperative neurological complications were not evaluated as potential predictors to avoid selection bias (all subjects who died experienced postoperative neurological complications and presented less time of hospitalization). For postoperative neurological complications, where adequate number of events was yielded (n=9), significant univariate predictors were further incorporated into the final multivariable logistic regression model. To address the small sample size of our study, we implemented exact logistic regression and resampling techniques. Exact logistic regression produces more accurate inference in small samples because it does not depend on asymptotic results and conditional maximum probability estimates were sequentially calculated for each predictor in multivariable logistic models by temporarily conditioning out the other independent variables. Bootstrapping with 1000 replications was conducted to replicate bias-corrected confidence intervals of the significant determinants of the outcomes on interest in univariate and multivariable regression models. However, due to the limited number of observations, the reported effect sizes for certain variables are still characterized by wide confidence intervals.

Statistical analysis was conducted using STATA package, version 11.1 (StataCorp, College Station, Texas, USA). We deemed statistical significance at P<0.05.

RESULTS

The cohort consisted of 34 male and 11 female patients. Mean age was 58±11.4 years. In 7 patients, haemodynamic instability and in 2 patients minor neurological deficits were noted preoperatively. Preoperative data and baseline demographic characteristics are shown in Table 1.

Table 1 - Baseline demographic and preoperative data.
Preoperative data No. of patients
Total n=45
Sex  
    Male 34 (75.6)
    Female 11 (24.4)
Age (years) 58±11.4
Mean body surface area (m2) 2±0.24
Preoperative creatinine plasma (mg/dL), median (IQR) 0.9 (0.8-1.3)
Preoperative hemodynamic instability 7 (15.6)
Previous cardiac surgery operation 2 (4.4)
Preoperative NT-proBNP (pg/mL), median (IQR) 247 (114-816)
Preoperative D-dimer (µg/L), median (IQR)  6503 (3418-8610)

Data are presented as mean ± SD or median (IQR) for continuous variables and as number and percentage for categorical variables.

IQR=interquartile range; NT-proBNP=N-terminal prohormone of brain natriuretic peptide; SD=standard deviation

Table 1 - Baseline demographic and preoperative data.

CPB was instituted with: right or left carotid (connecting through a synthetic 10-mm graft)/bicaval cannulation in 42 patients and femoral artery/bicaval cannulation in 3 patients. Combined procedures were performed in 12 patients. Median circulatory arrest time was 41.5 (30-54) min and median minimum bladder temperature during circulatory arrest was 22.3 (20.8-24) °C. Other perioperative details are presented in Table 2.

Table 2 - Perioperative data.
Perioperative data No. of patients Total n=45 (%)
Combined operations 12 (26.7)
Types of operations  
Interposition graft replacement 29 (64.4)
Interposition graft replacement + modified Bentall operation 5 (11.1)
Interposition graft replacement + aortic valve replacement 3 (6.7)
Interposition graft replacement + coronary bypass grafting 2 (4.4)
Interposition graft replacement + aortic arch replacement 6 (13.3)
Total circulatory arrest time (min), median (IQR) 41.5 (30-54)
Aortic cross-clamp time (min), median (IQR) 107 (92-130)
Cardiopulmonary bypass time (min), median (IQR) 211 (184-240)
Bladder temperature during circulatory arrest (°C), median (IQR) 22.3 (20.8-24)
pH during circulatory arrest, median (IQR) 7.33 (7.29-7.35)

Data are presented as mean ± SD or median (IQR) for continuous variables and as number and percentage for categorical variables.

IQR=interquartile range; SD=standard deviation

Table 2 - Perioperative data.

Major and minor postoperative complications and follow-up data such as postoperative atrial fibrillation (AF), postoperative open sternum, intensive care unit (ICU) stay, all postoperative neurological complications, 30-day mortality and other complications are listed in Table 3. During median follow-up of 6 (2-12) months the survival was 86.7% (39/45).

Table 3 - Postoperative complications and follow-up data.
Postoperative complications and follow-up data No. of Patients Total n=45 (%)
Atrial fibrillation 11 (24.4)
Permanent pacemaker 2 (4.4)
Pericardial effusion 5 (11.1)
Mechanical ventilation > 48 hours in intensive care unit 29 (64.4)
Postoperative open sternum 14 (31.1)
Postoperative acute kidney injury (increase postoperative >50 % of preoperative creatinine plasma) 23 (51.1)
Postoperative neurological dysfunction:  
No neurological dysfunction 36 (80)
Temporary neurological dysfunction ___
Permanent neurological dysfunction 6 (13.3)
Heavy neurological dysfunction 3 (6.7)
Postoperative transfusion of red blood cells (unit), median (range) 10 (2-38)
Postoperative transfusion of fresh frozen plasma (unit), median (range) 8 (3-36)
Postoperative creatinine plasma (mg/dL), median (IQR) 1.6 (1.3-2.3)
Postoperative stay in ICU (days), median (IQR) 8 (3-9)
Postoperative in-hospital stay (days), median (IQR) 12 (8-18)
Follow-up (months), median (IQR) 6 (2-12)
Overall mortality 6 (13.3)
30-days mortality 3 (6.7)
All cause deaths during median follow-up 6 (2-12) months 3 (6.7)

Data are presented as mean ± SD or median (IQR) for continuous variables and as number and percentage for categorical variables.

Permanent neurological dysfunction (PND)=hemiplegia or paraplegia >48 hours after discharge at home. Heavy neurological deficits=diffuse and irreversible brain damage or coma.

ICU=intensive care unit; IQR=interquartile range

Table 3 - Postoperative complications and follow-up data.

Unadjusted analysis of factors associated with 30-day mortality showed: preoperative hemodynamic instability (OR: 14.8, 95% CI: 2.41, 90.6, P=0.004) and postoperative open sternum (OR: 5.0, 95% CI: 1.041, 24.0, P=0.044) (Table 4).

Table 4 - Univariate risk factors for 30-day mortality.
Variable No. of patients 30-day mortality OR 95% CI P-value
Overall 45 3 (6.7)      
Preoperative factors          
    Age (years) 58±11.4   0.909 (0.805-1.01) 0.071*
    Sex (female) 11 (26.19) __ 0.775 (0-7.7) 0.565
    Preoperative hemodynamic instability 7 (15.6) 2 (4.4) 14.8 (2.41-90.6) 0.004*
    Preoperative D-dimer     1.001 (0.999-1.001) 0.798
    Preoperative NT-proBNP     1.002 (0.999-1.001) 0.658
Perioperative factors          
    Arterial cannulation site (femoral artery) 3 (6.7) __ 3.74 (0-44.3) 0.999
    Total aortic arch replacement 7 (15.6) __ 1.39 (0.14-15.9) 0.999
    Combined operation 12 (26.7) __ 0.687 (0-6.8) 0.554
    Cardiopulmonary bypass time     0.991 (0.955-1.019) 0.581
    Aortic cross-clamp time     0.986 (0.933-1.028) 0.584
    Total circulatory arrest time     0.957 (0.853-1.029) 0.374
    Bladder temperature during circulatory arrest     1.29 (0.829-2.01) 0.227
Postoperative factors          
    Postoperative open sternum 14 (31.1) 2 (4.4) 5 (1.041-24.0) 0.044*
    Postoperative pericardial effusion 5 (11.1) __ 2.07 (0-22) 0.999
    Postoperative atrial fibrillation 11 (24.4) __ 0.775 (0-7.7) 0.565
    Postoperative stay in ICU     0.581 (0.299-1.127) 0.108

P-values are derived from exact univariate logistic regression.

* Confidence intervals are derived from bootstrapping with 1000 replications.

NT-proBNP=N-terminal prohormone of brain natriuretic peptide; ICU=intensive care unit

Table 4 - Univariate risk factors for 30-day mortality.

Furthermore, unadjusted analysis revealed that severe neurological dysfunction correlated with: preoperative hemodynamic instability (OR: 8.8, 95% CI: 1.41, 54.9, P=0.02) and postoperative sepsis or multiple organ dysfunction (OR: 13.6, 95% CI: 2.1, 89.9, P=0.007) while bladder temperature during circulatory arrest (˚C) (OR: 1.33, 95% CI: 0.980, 1.860, P=0.058) was marginally associated with this outcome (Table 5). Finally, by multivariate logistic regression analysis, postoperative sepsis/multiple organ dysfunction was associated (OR: 15.9, 95% CI: 1.05, 96.4, P=0.045) with the incidence of severe postoperative neurological complications (Table 6) independently of other significant univariate predictors (i.e. bladder temperature during circulatory arrest and presence of preoperative hemodynamic instability).

Table 5 - Univariate risk factors for postoperative severe neurological complication.
Variable No. of patients Postoperative neurological complication OR 95% CI P-value
Overall 45 (100.0)        
Preoperative factors          
    Age (years) 58±11.4   0.977 (0.915-1.042) 0.489
    Sex (female) 11 (26.19) 1 (2.2) 0.338 (0.007-3.1) 0.416
    Reoperation 2 (4.4) __ 1.64 (0-22) 0.999
    Preoperative hemodynamic instability 7 (15.6) 4 (8.9) 8.8 (1.41-54.9) 0.02*
    Preoperative NT-proBNP     0.999 (0.999-1.001) 0.621
Perioperative factors          
    Arterial cannulation site (common carotid artery with graft) 42 (93.3) 8 (17.8) 0.480 (0.022-31) 0.999
    Arterial cannulation site (femoral artery) 3 (6.7) 1 (2.2) 2.13 (0.426-10.6) 0.358
    Total aortic arch replacement 7 (15.6) 2 (4.4) 1.75 (0.139-13.8) 0.614
    Combined operation 12 (26.7) 2 (4.4) 0.748 (0.065-4.93) 0.999
    Cardiopulmonary bypass time     1.002 (0.985-1.018) 0.805
    Aortic cross-clamp time     1.01 (0.981-1.029) 0.673
    Total circulatory arrest time     1.01 (0.974-1.037) 0.686
    Bladder temperature during circulatory arrest     1.33 (0.980-1.86) 0.058*
Postoperative factors          
    Postoperative open sternum 14 (31.1) 3 (6.7) 1.13 (0.155-6.6) 0.999
    Postoperative acute kidney injury 23 (51.1) 6 (13.3) 2.2 (0.394-15.7) 0.459
    Postoperative pericardial effusion 5 (11.1) 1 (2.2) 1 (0.018-12.2) 0.999
    Postoperative permanent pacemaker implantation 2 (4.4) __ 1.64 (0-22) 0.999
    Postoperative atrial fibrillation 11 (24.4) 3 (6.7) 1.73 (0.228-10.6) 0.666
    Postoperative sepsis or multiple organ dysfunctions 6 (13.3) 4 (8.9) 13.6 (2.1-89.9) 0.007*
    Postoperative stay in ICU     1.040 (0.966-1.12) 0.254
    Postoperative hospital stay     1.031 (0.982-1.1) 0.180

P-values are derived from exact univariate logistic regression.

* Confidence intervals are derived from bootstrapping with 1000 replications.

NT-proBNP=N-terminal prohormone of brain natriuretic peptide; ICU=intensive care unit

Table 5 - Univariate risk factors for postoperative severe neurological complication.
Table 6 - Multivariable logistic regression analysis for the main determinants of the incidence of postoperative severe neurological outcome (n=45).
Variable OR 95% CI P-value
Bladder temperature during circulatory arrest 1.28 0.885-1.89 0.183
Preoperative hemodynamic instability 5.5 0.454-77 0.221
Postoperative sepsis or multiple organ dysfunction 15.9 1.05-96.4 0.045*

P-values are derived from exact logistic regression.

Table 6 - Multivariable logistic regression analysis for the main determinants of the incidence of postoperative severe neurological outcome (n=45).

DISCUSSION

Publications of series on operations in the ascending aorta and hemiarch continue to discuss advantages and disadvantages amongst different techniques particularly in AAD pathology[1-7]. However, there is unanimity in that the most significant concern during this type of operations is the protection of the central nervous system (CNS) during the interval of hypothermic CA. The main issues that need to be addressed in these complex procedures are route of CPB establishment (site of arterial cannulation), core temperature management during operation and type of cerebral perfusion during CA with or without aortic arch repair.

Arterial Cannulation Sites

The optimal arterial cannulation site during proximal aortic arch surgery has been widely discussed over the years. Direct cannulation of the ascending aorta in patients who have an aortic aneurysm is an accepted technique and supported by many authors[8]. On the other hand, in cases with acute and chronic aortic dissection, the approach of arterial cannulation is controversial. Many techniques have been suggested in these cases: ascending aortic cannulation, right axillary or subclavian artery, right or left carotid artery, right or left common femoral artery and even transapical aortic cannulation[9-14]. These studies have demonstrated a relatively similar 30-day mortality regardless of the cannulation technique, while the incidence of stroke varied widely between 3.8 and 21%. In 2010, Tiwari et al.[15], after analysis of several studies, concluded that ascending aortic cannulation has promising results with a lower mortality rate, but a higher stroke rate in type A aortic dissections. In our study, the incidence of PND and 30-day mortality was 13.3% and 6.7%, respectively. Although the numbers of patients in our study are too small to draw safe conclusions, the survival rate seems to be very good, with good survival in the medium term. Neurological complications, however, according to the above remain an issue.

Temperature Management during Hypothermic Circulatory Arrest

The goals of hypothermia during thoracic aortic surgery are reduction of brain metabolism and attenuation of CNS damage during CA. In 1975, Griepp et al.[16] described four patients with successful outcome who underwent aortic arch replacement with prosthetic graft under deep hypothermic circulatory arrest (DHCA) with lowest esophageal temperature at 14°C and lowest rectal temperature at 18°C. Decreased mortality and neurological complications were achieved with cerebral perfusion during CA. Deep hypothermic circulatory arrest with retrograde cerebral perfusion (DHCA/RCP) (18°C) allowed longer CA times and improved brain protection[17]. In 1991, Bachet et al.[18] published the technique with MHCA/ACP during transverse aortic arch repair (core temperature 25-28°C and brain perfused with blood cooled at 6-12°C). This method created a favorable circumstance to perform more complex operations in the aortic arch, with simultaneous improvement of neurological and overall outcomes.

In 2011, the analysis of 1558 patients (GERAADA study) by Krüger et al.[19] noted that relative increase in mortality was observed in patients with hypothermic CA (<15°C) alone, even more so when CA arrest time exceeded 30 min. Estrera et al.[20] used hypothermic CA (nasopharyngeal temperature 15-20°C) with or without retrograde cerebral perfusion (RCP) and stroke rate and 30-day mortality were 2.3% and 10.4%, respectively. On the other hand, Urbanski et al.[21] analyzed 347 patients who underwent non-emergent arch surgery under MHCA with rectal temperature (28-34°C) utilizing ACP. Their 30-day mortality and overall postoperative neurological dysfunction were 0.9% and 3.2%, respectively. Perreas et al.[22], in a retrospective analysis of 208 patients operated on with DHCA/RCP (temperature range 11-24°C), concluded that the core temperature within the specific range was not a risk factor for 30-day mortality and severe neurological events. In another recent study, Zierer et al.[4] noted that increase of the core temperature (28-30°C) during CA with implementation ACP allowed more time (CA>90 min), more complex corrections of ascending aorta and aortic arch pathology with low incidence of postoperative complications (new postoperative neurological deficits were 7%). Leshnower et al.[23] analyzed 500 patients who underwent a hemiarch replacement under mild (28.6°C) vs. moderate (24.3°C) hypothermic CA with unilateral ACP with operative mortality of 4.2% vs. 4.8% (P=0.80) and no differences in TND between the two groups. However, the incidence of PND was reduced in mild vs. moderate hypothermia (2.5% vs.7.2%) (P=0.01).

Type of the cerebral protection and perfusion: DHCA alone, DHCA/RCP, deep hypothermic CA with unilateral or bilateral cerebral perfusion (DHCA/UACP or BACP), or moderate hypothermic CA with unilateral or bilateral cerebral perfusion (MHCA/UACP or BACP)?

In hemiarch with or without total aortic arch replacement, with or without stent grafting, the question remains: which method of brain protection is most effective and safe during these complex operations, particularly in patients with AAD?

Usui et al.[1] analyzed 2792 patients and found no differences between the ACP and RCP groups in 30-day mortality (3.4% vs. 2.4%) and stroke rate (5% vs. 3%), but in the subgroup with RCP higher incidence of transient neurological dysfunction (5.8%) was observed. Misfeld et al.[2] divided 636 patients who underwent aortic arch surgery in four groups: UACP, bilateral ACP (BACP), DHCA/RCP and DHCA only. The study showed that early mortality and five-year survival were not different between the surgical groups, but stroke rate was different in patients who did not receive ACP (P=0.035). Urbanski et al.[21] presented results of non-emergent aortic arch surgery using mild to moderate hypothermic CA (31.5±1.6°C) with ACP (blood temperature 28°C) in 347 patients. The results show that 30-day mortality was 0.9%, and PND and TND observed in 0.9% and 2.3%, respectively. On the other hand, Estrera et al.[20] reported the study with 1107 patients who operated under DHCA/RCP in 82% of cases, and the results were 30-day mortality and stroke rate occurred 10.4% and 2.8%, respectively. After comparative analysis of 1558 patients with AAD, Krüger et al.[19] concluded that 30-day mortality was higher in the DHCA group (19.4%) than in the BACP (15.9%) and UACP (13.9%) groups (P<0.05). The same study noted that PND were: DHCA-14.9%, BACP-14.1% and UACP-12.6%. The most recent results from the Japanese AAD database (2016) repair with ACP vs. RCP did not show significant differences regarding mortality and postoperative neurological dysfunctions rates (11.2% vs. 9.7%)[3]. Nowadays, many studies discuss the incidence of stroke and mortality rate after AAD repair with hemiarch versus hemiarch plus total arch replacement (with or without antegrade stent grafting)[3,24-26]. After analysis, the results show that the rates of mortality and stroke are similar between the two groups. However, it is possibly relevant regarding false lumen thrombosis rate and reduction of late reoperation rate in aortic arch and descending aorta. In 2015, Di Bartolomeo et al.[26], in a review of AAD type A repair with frozen elephant trunk technique, noted that mortality and postoperative stroke range were 0-27.7% and 0-12%, respectively. In addition, in the same study, the authors revealed that the spinal cord injury rate ranged from 0 to 13.8%. It is evident that postoperative neurological complications range in the literature from 0 to 39.7%.

CONCLUSION

In aortic arch surgery for AAD, the total CA can be avoided by maintaining cerebral perfusion. Thus, continuous cerebral perfusion via UACP or BACP resulted in a reduction of postoperative mortality. However, the postoperative severe neurological complications remain at high frequency, requiring further refinement of this technique. Reduction of these major postoperative complications should be explored in multicenter studies.

Limitations

This is clearly a retrospective analysis with a small cohort, albeit with consecutive patients from a single unit. Two patients with preoperative TIA were included in our study with possible impact on severe postoperative neurological complications. Furthermore, most patients with AAD were operated emergently without accurate preoperative neurological assessment and without preoperative brain CT. On the other hand, more extensive follow-up is required to demonstrate potential improvements in the long-term outcomes.


REFERENCES

1. Usui A, Miyata H, Ueda Y, Motomura N, Takamoto S. Risk-adjusted andcase-matched comparative study between antegrade and retrograde cerebralperfusion during aortic arch surgery: based on the Japan Adult CardiovascularSurgery Database: the Japan Cardiovascular Surgery Database Organization. GenThorac Cardiovasc Surg. 2012;60(3):132-9.

2. Misfeld M, Leontyev S, Borger MA, Gindensperger O, Lehmann S, LegareJF, et al. What is the best strategy for brain protection in patients undergoingaortic arch surgery? A single center experience of 636 patients. Ann ThoracSurg. 2012;93(5):1502-8.

3. Okita Y. Current surgical results of acute type A aortic dissectionin Japan. Ann Cardiothorac Surg. 2015;5(4):368-76.

4. Zierer A, El-Sayed Ahmad A, Papadopoulos N, Moritz A, Diegeler A,Urbanski PP. Selective antegrade cerebral perfusion and mild (28°C-30°C)systemic hypothermic circulatory arrest for aortic arch replacement: resultsfrom 1002 patients. J Thorac Cardiovasc Surg.2012;144(5):1042-9.

5. Sugiura T, Imoto K, Uchida K, Minami T, Yasuda S. Comparative studyof brain protection in ascending aorta replacement for acute type A aorticdissection: retrograde cerebral perfusion versus selective antegrade cerebralperfusion. Gen Thorac Cardiovasc Surg. 2012;60(10):645-8.

6. Han QQ, Song ZG, Zou LJ, Han L, Lu FL, Lang XL, et al. Reinforcedaortic root reconstruction for acute type A aortic dissection involving theaortic root. Rev Bras Cir Cardiovasc. 2013;28(2):190-9.

7. Pinheiro BB, Fagundes WV, Muniz LF, Dreifaldt M, Arbeus M, Souza DS.Dacron graft intussusception technique for treatment of type A aorticdissections: technical notes and preliminary results. Braz J Cardiovasc Surg.2016;31(2):115-9.

8. Khaladj N, Shrestha M, Peterss S, Strueber M, Karck M, Pichlmaier M,et al. Ascending aortic cannulation in acute aortic dissection type A: theHannover experience. Eur J Cardiothorac Surg. 2008;34(4):792-6.

9. Fusco DS, Shaw RK, Tranquilli M, Kopf GS, Elefteriades JA. Femoralcannulation is safe for type A dissection repair. Ann Thorac Surg.2004;78(4):1285-9.

10. Strauch JT, Spielvogel D, Lauten A, Lansman SL, McMurtry K, BodianCA, et al. Axillary artery cannulation: routine use in ascending aorta andaortic arch replacement. Ann Thorac Surg. 2004;78(1):103-8.

11. Wada S, Yamamoto S, Honda J, Hiramoto A, Wada H, Hosoda Y.Transapical aortic cannulation for cardiopulmonary bypass in type A aorticdissection operations. J Thorac Cardiovasc Surg.2006;132(2):369-72.

12. Urbanski PP, Lenos A, Lindemann Y, Weigang E, Zacher M, Diegeler A.Carotid artery cannulation in aortic surgery. J Thorac Cardiovasc Surg.2006;132(6):1398-403.

13. Kamiya H, Kallenbach K, Halmer D, Ozsöz M, Ilg K, Lichtenberg A, etal. Comparison of ascending aorta versus femoral artery cannulation for acuteaortic dissection type A. Circulation. 2009;120(11Suppl):S282-6.

14. Sosnowski AW, Jutley RS, Masala N, Alexiou C, Swanevelder J. How Ido it: transapical cannulation for acute type-A aortic dissection. JCardiothorac Surg. 2008;3:4.

15. Tiwari KK, Murzi M, Bevilacqua S, Glauber M. Which cannulation(ascending aortic cannulation or peripheral arterial cannulation) is better foracute type A aortic dissection surgery? Interact Cardiovasc Thorac Surg.2010;10(5):797-802. [MedLine]

16. Griepp RB, Stinson EB, Hollingsworth JF, Buehler D. Prostheticreplacement of the aortic arch. J Thorac Cardiovasc Surg.1975;70(6):1051-63.

17. Ueda Y, Miki S, Kusuhara K, Okita Y, Tahata T, Yamanaka K. Deephypothermic systemic circulatory arrest and continuous retrograde cerebralperfusion for surgery of aortic arch aneurysm. Eur J Cardiothorac Surg.1992;6(1):36-41.

18. Bachet J, Guilmet D, Goudot B, Termignon JL, Teodori G, Dreyfus G,et al. Cold cerebroplegia. A new technique of cerebral protection duringoperations on the transverse aortic arch. J Thorac Cardiovasc Surg.1991;102(1):85-93.

19. Krüger T, Weigang E, Hoffmann I, Blettner M, Aebert H; GERAADAInvestigators. Cerebral protection during surgery for acute aortic dissectiontype A: results of the German Registry for Acute Aortic Dissection Type A(GERAADA). Circulation. 2011;124(4):434-43.

20. Estrera AL, Miller CC 3rd, Lee TY, Shah P, Safi HJ. Ascending andtransverse aortic arch repair: the impact of retrograde cerebral perfusion.Circulation. 2008;118(14 Suppl):S160-6.

21. Urbanski PP, Lenos A, Bougioukakis P, Neophytou I, Zacher M,Diegeler A. Mild-to-moderate hypothermia in aortic arch surgery usingcirculatory arrest: a change of paradigm? Eur J Cardiothorac Surg.2012;41(1):185-91.

22. Perreas K, Samanidis G, Dimitriou S, Kalogris P, Balanika M, AntzakaC, et al. Outcomes after ascending aorta and proximal aortic arch repair usingdeep hypothermic circulatory arrest with retrograde cerebral perfusion: analysisof 207 patients. Interact Cardiovasc Thorac Surg.2012;15(3):456-61.

23. Leshnower BG, Myung RJ, Thourani VH, Halkos ME, Kilgo PD, Puskas JD,et al. Hemiarch replacement at 28°C: an analysis of mild and moderatehypothermia in 500 patients. Ann Thorac Surg.2012;93(6):1910-5.

24. Vallabhajosyula P, Gottret JP, Robb JD, Szeto WY, Desai ND,Pochettino A, et al. Hemiarch replacement with concomitant antegrade stentgrafting of the descending thoracic aorta versus total arch replacement fortreatment of acute DeBakey I aortic dissection with arch tear. Eur JCardiothorac Surg. 2016:49(4):1256-61.

25. Omura A, Miyahara S, Yamanaka K, Sakamoto T, Matsumori M, Okada K,et al. Early and late outcomes of repaired acute DeBakey type I aorticdissection after graft replacement. J Thorac Cardiovasc Surg.2016;151(2):341-8.

26. Di Bartolomeo R, Pantaleo A, Berretta P, Murana G, Castrovinci S,Cefarelli M, et al. Frozen elephant trunk surgery in acute aortic dissection. JThorac Cardiovasc Surg. 2015;149(2 Suppl):S105-9.

Article received on june 18, 2017.

Article accepted on september 6, 2017.

No conflict of interest.
No financial support.

Authors' roles & responsibilities

GS Took part in the care of the patients and contributed equally in data collection and manuscript preparation; final approval of the version to be published

CK Took part in the care of the patients and contributed equally in data collection and manuscript preparation; final approval of the version to be published

CC Took part in the care of the patients and contributed equally in data collection and manuscript preparation; final approval of the version to be published

GG Contributed in the statistical analysis of the data; final approval of the version to be published

IK Took part in the care of the patients and contributed equally in data collection and manuscript preparation; final approval of the version to be published

TA Took part in the care of the patients and contributed equally in data collection and manuscript preparation; final approval of the version to be published

KP Supervision of this report; final approval of the version to be published

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