George Matalanis, Rhiannon KoiralaAustin Medical CentreMelbourne, Australia

Branch First Aortic Arch Repair

Aortic Symposium 2010AATS

Without Deep HypothermiaOr Circulatory Arrest

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 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

Rightcarotid

Subclavian

Upper body

É Leftcarotid

Externalcarotid É

Internalcarotid

Carotid

É

É

Lower body

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

Reconstruction Sequence

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

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 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 Re-exploration: 3 (10%) Mechanical Cardiac support: 1*(3.3%) Renal support: 1* (3.3%) Tracheostomy: 1 (3.3%) Sternal infection: nil* mortality

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 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