Improving Results of Open Arch Replacement

Background: The rapid evolution of endovascular approaches to arch reconstruction such as brachiocephalic debranching and endovascular stent grafting renders an accurate understanding of contemporary outcomes of conventional open arch surgery particularly relevant. Methods: Cases of arch reconstruction were identified by search of the computerized cardiovascular surgical database. Perioperative (30-day) outcomes as per The Society of Thoracic Surgeons database were evaluated. Results: Between January 1, 1993, and June 30, 2007, 347 patients (195 male, 152 female; median age, 69 years; range, 21 to 88 years) underwent aortic arch replacement. Procedures were elective in 232 cases. Total arch replacement was performed in 95, including 15 with concomitant replacement of the descending thoracic aorta by means of bilateral thoracosternotomy. Modalities adjunctive to profound hypothermia and circulatory arrest for cerebral protection have been introduced, including retrograde cerebral perfusion and, more recently, selective antegrade cerebral perfusion. The overall mortality rate was 8.9% (elective procedures, 6.0%) and stroke rate was 8.4% (elective procedures, 6.9%). The mortality rate for total arch replacement has declined with adjuncts overall from 34.6% (9 of 26) with profound hypothermia and circulatory arrest to 21.1% (4 of 19) with retrograde cerebral perfusion and to 6.0% (3 of 50) with selective antegrade cerebral perfusion (p < 0.01), and for elective cases from 30.0% (6 of 20) with profound hypothermia and circulatory arrest to 14.3% (2 of 14) with retrograde cerebral perfusion, and 2.7% (1 of 37) with selective antegrade cerebral perfusion (p < 0.01). The corresponding stroke rates were 19.2% (5 of 26) with profound hypothermia and circulatory arrest, 5.3% (1 of 19) with retrograde cerebral perfusion, and 6.0% (3 of 50) with selective antegrade cerebral perfusion (p = 0.18) overall and 15.0% (3 of 20) with profound hypothermia and circulatory arrest, 7.1% (1 of 14) with retrograde cerebral perfusion, and 5.4% (2 of 37) with selective antegrade cerebral perfusion (p = 0.46) for elective cases. Conclusions: Currently, open aortic arch replacement can be accomplished under elective circumstances with low operative mortality, particularly with adjunctive measures for cerebral protection. The results of endovascular therapies should be measured against contemporary surgical series.