Use of carotid–subclavian arterial bypass and thoracic endovascular aortic repair to minimize cerebral ischemia in total aortic arch reconstruction

Xydas, Steve; Wei, Benjamin; Takayama, Hiroo; Russo, Mark; Bacchetta, Matthew; Smith, Craig R.; Stewart, Allan

doi:10.1016/j.jtcvs.2009.10.040

« Previous Next »The Journal of Thoracic and Cardiovascular Surgery
Volume 139, Issue 3 , Pages 717-722, March 2010

Use of carotid–subclavian arterial bypass and thoracic endovascular aortic repair to minimize cerebral ischemia in total aortic arch reconstruction

Steve Xydas, MD
- Gagnon Cardiovascular Institute, Department of Cardiovascular Medicine, Morristown Memorial Hospital, Morristown, NJ
- Address for reprints: Steve Xydas, MD, Gagnon Cardiovascular Institute, Morristown Memorial Hospital, 100 Madison Ave, Morristown, NJ 07960.
Benjamin Wei, MD
- Division of Cardiothoracic Surgery, Columbia University College of Physicians and Surgeons, New York, NY
Hiroo Takayama, MD
- Division of Cardiothoracic Surgery, Columbia University College of Physicians and Surgeons, New York, NY
Mark Russo, MD
- Division of Cardiothoracic Surgery, Columbia University College of Physicians and Surgeons, New York, NY
Matthew Bacchetta, MD
- Division of Cardiothoracic Surgery, Columbia University College of Physicians and Surgeons, New York, NY
Craig R. Smith, MD
- Division of Cardiothoracic Surgery, Columbia University College of Physicians and Surgeons, New York, NY
Allan Stewart, MD
- Division of Cardiothoracic Surgery, Columbia University College of Physicians and Surgeons, New York, NY

Received 26 July 2009; received in revised form 28 September 2009; accepted 25 October 2009. published online 18 January 2010.

Objective

Total aortic arch replacement typically requires hypothermic circulatory arrest, carrying risks of cerebral ischemia. We recently introduced left carotid–subclavian bypass before total aortic arch replacement with thoracic stent grafting to achieve hybrid arch reconstruction with short periods of selective antegrade cerebral perfusion.

Methods

From 2004 to 2009, 332 patients underwent ascending aorta or arch replacements. Of these, 37 underwent total aortic arch replacement. In 2008, we began performing left carotid–subclavian bypass before subtotal arch replacement, with side-graft anastomoses to innominate and left carotid arteries. Patients then underwent aortic graft stent deployment to complete arch reconstruction. Twenty-eight patients underwent conventional arch replacement (group I); 9 underwent hybrid arch replacement (group II).

Results

Selective antegrade cerebral perfusion time in group I was 33.3 ± 13.7 minutes versus 18.9 ± 9.2 minutes in group II (P = .007). Among group I patients, 82% required hypothermic circulatory arrest (vs 0% in group II, P < .001). Mean cardiopulmonary bypass and aortic crossclamp times were longer in group I than group II (P < .05). Incidence of neurologic complications was 14% in group I (4/28) versus 0% (0/9) in group II, although this finding did not reach statistical significance (P = .55).

Conclusions

Left carotid–subclavian bypass before arch replacement with staged thoracic stent grafting to achieve hybrid arch reconstruction was associated with decreased selective antegrade cerebral perfusion, cardiopulmonary bypass, and aortic crossclamp times and eliminated hypothermic circulatory arrest. This technique may minimize neurologic complications associated with arch replacement and provide a viable hybrid approach to patients with arch aneurysms and dissections.

Abbreviations and Acronyms: CPB, cardiopulmonary bypass, CSB, carotid–subclavian arterial bypass, HCA, hypothermic circulatory arrest, SACP, selective antegrade cerebral perfusion, TAAR, total aortic arch replacement, TEVAR, thoracic endovascular aneurysm repair