Aortic arch disease. Contemporary open surgical treatment strategies

Abstract

Introduction and methods

Surgery of the aortic arch is one of the most challenging procedures in cardiac surgery requiring mastery of temporary manipulation of cerebral and systemic circulation. The purpose of this article is to describe the evolution of the approach to open repair of the aortic arch and its technical peculiarities.

Results

Different cannulation and perfusion strategies may have a different effect on postoperative outcomes. Classically, organ protection was achieved by drastically reducing oxygen demand through hypothermia; currently, this is combined with antegrade cerebral perfusion to increase the safe time of interruption of the aortic arch without increasing neurological risk. Axillary artery cannulation in combination with other sources of cerebral perfusion is a proven and reproducible strategy.

Continuous selective cerebral perfusion throughout surgery has allowed surgery to be performed at more moderate temperatures, which has been shown to reduce surgical times, postoperative bleeding and the rate of neurological complications compared to deep hypothermia.

Despite these improvements, surgical times and systemic circulatory arrest remain the main determinants of perioperative morbi-mortality. Recently, the strategy of normothermic circulation without interruption of perfusion of the lower body – in selected cases – has been adopted for a more physiological repair of the aortic arch.

Conclusions

Overall, arch surgery requires extensive planning based on the aortic arch, supra-aortic vessels and cerebral anatomy. Therefore, the choice of arterial cannulation, organ perfusion strategy and the temperature at which the repair is completed should be individualized to the patient.