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Aortic Symposium 2010 AATS. Branch First Aortic Arch Repair. Without Deep Hypothermia Or Circulatory Arrest. George Matalanis, Rhiannon Koirala Austin Medical Centre Melbourne, Australia. Problems with Current Techniques. Circulatory arrest (CA) Maximum “safe” period

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Aortic Symposium 2010

AATS

Branch First Aortic Arch Repair

Without Deep Hypothermia

Or Circulatory Arrest

  • George Matalanis, Rhiannon Koirala
  • Austin Medical Centre
  • Melbourne, Australia
problems with current techniques
Problems with Current Techniques
  • Circulatory arrest (CA)
    • Maximum “safe” period
    • Opportunity for air/debris embolism
  • Deep hypothermia (DH)
    • Prolonged bypass
    • Coagulopathy
  • Retrograde Cerebral perfusion
    • Negligible nutritive flow
  • Unilateral Antegrade Perfusion
    • Contralateral hypoperfusion
    • Ipsilateral hyperperfusion
  • Bilateral Antegrade Perfusion
    • Direct cannulation risks
    • View obstruction
collateral anatomy
Collateral Anatomy
  • NOT like Carotid Endarterectomy
    • Without shunt complete reliance on CIRCLE OF WILLIS
      • 15% inadequate ICA stump pressure
      • Even then Stroke risk < 3% if clamp time < 10-15 min
collaterals available in individual proximal arch branch clamping
Collaterals Available in IndividualProximal Arch Branch Clamping

Subclavian

Right

carotid

Left

carotid

Carotid

Upper body

External

carotid

Internal

carotid

Lower body

cannulation and bypass
Cannulation and bypass
  • Dual upper and lower body inflow
    •  pressure gradients
    • Maintenance of body perfusion after innominate clamping
    • Direct Ascending Aorta -alternative in PVD/thoraco-abdominal atheroma
patients
Patients
  • 30 cases: Jul 2005- Oct 2009
  • Male : Female = 19:11
  • Age: 62 (28-85)
  • Smoking: 57%
  • Hypertension: 63%
  • CVD: 23%
  • CAD: 30%
  • Elective
    • 18 (60%)
  • Urgent/Emergent
    • 12 (40%)
  • Type A dissection
    • 16 (53%)
  • Re-operation
    • 4 (13%)
concomitant procedures
Concomitant Procedures
  • Aortic Root:19 (63%)
    • Valve sparing: 14 (74%)
      • David: 3
      • Other valve sparing: 11
    • Bentall’s: 5 (26%)
      • Mechanical: 3
      • Tissue: 2
  • Separate AVR: 2 (7%)
  • Elephant Trunk: 4 (13%)
    • Regular: 2
    • Frozen: 2
  • CABG: 6 (20%)
early outcomes
Early outcomes
  • Mortality: 1 (3.3%)
    • 85 y.o, late presenting Ac Type A
  • Neurological Dysfunction: 4 (13%)
    • All focal/embolic:
      • Amourosis Fugax
      • Hemianopia,
      • Hemiparesis,
      • Dysphasia.
    • Complete recovery: 3
    • Residual deficit: 1 (hemianopia)
other morbidity
Other Morbidity
  • Re-exploration: 3 (10%)
  • Mechanical Cardiac support: 1*(3.3%)
  • Renal support: 1* (3.3%)
  • Tracheostomy: 1 (3.3%)
  • Sternal infection: nil

* mortality

benefits
Benefits
  • Ventilation < 24 hrs: 12 (40%)
  • ICU stay < 2 days: 14 (47%)
  • Hospital stay ≤ 7 days: 10 (33%)
  • NO TRANSFUSION: 8 (26.7%)
    • 2 of these were re-operative cases
conclusions
Conclusions
  • Branch First aortic arch repair is a safe procedure :
    • 3.3% Mortality
    • 3.3% permanent Stroke
  • Applicable to urgent and complex cases
  • Haemostatic
    • 27% no blood/product transfusion
  • Better visceral organ protection
    • 1.3% CVVH
  • Allows complete and unhurried repair
    • Avoid late deaths from undertreated aortic segments
    • Avoid difficult redo for persistent/recurrent aortic pathology