Importance of Left Subclavian Artery Perfusion for Cerebral Protection: A Novel Technique Eliminating DHCA in Total Arch Replacement Using Left Axillar Artery for Arterial Cannulation

P0164 

Abstract Submission 

Ugursay Kiziltepe (1), Ilker Ince (2), Suleyman Surer (3), IBRAHIM DUVAN (4), Omer Delibalta (5), Melike Senkal (6), Ozgur Ersoy (7), Kasim Karapinar (8)

(1) Diskapi YBEA Hospital, Çankaya, Select State, (2) Etlik Sehir Hastanesi, ANKARA, NA, (3) Etlik Sehir Hastanesi, Ankara, NA, (4) Ankara Etlik Sehir Hastanesi, ANKARA, NA, (5) Diskapi YBEA Hospital, ANKARA, NA, (6) N/A, N/A, (7) Etlik Sehir Hastanesi, ANKARA, Ankara, (8) Ankara EA Hastanesi, ANKARA, Ankara

Ugursay Kiziltepe    -  Contact Me
Diskapi YBEA Hospital

Ilker Ince    -  Contact Me
Etlik Sehir Hastanesi

Suleyman Surer    -  Contact Me
Etlik Sehir Hastanesi

IBRAHIM DUVAN    -  Contact Me
Ankara Etlik Sehir Hastanesi

Omer Delibalta    -  Contact Me
Diskapi YBEA Hospital

Melike Senkal    -  Contact Me
N/A

Ozgur Ersoy    -  Contact Me
Etlik Sehir Hastanesi

Kasim Karapinar    -  Contact Me
Ankara EA Hastanesi

Ugursay Kiziltepe    -  Contact Me
Diskapi YBEA Hospital

Objective: Total aortic arch replacement (TAR) necessitates hypothermic circulatory arrest (CA). Stroke and spinal cord injury are major complications following TAR with FET technique, which is performed typically with antegrade selective cerebral perfusion (ACP) omitting left subclavian artery (LSA) and additionally requires commercial hybrid grafts. However, left vertebral artery (VA) is dominant in 60% of population, whereas right VA dominance is only 15%. Considering VAs are the sole source of blood flow to spinal cord during ACP, a complete circle of Willis is seen in only 20-25% of population, and 1/3 of cases have hypoplastic posterior communicating arteries; varying degrees of neurologic impairments could be explained if not a major stroke after extended periods of ACP. Herein, we describe a novel modified FET technique that not only eliminates CA but also provides more complete cerebral and spinal cord perfusion using standard grafts thanks to left axillary artery (LAxA) cannulation in patients with acute type A aortic dissection.

Methods: A home-made debranching graft is constructed and consists of one large branch for innominate artery (IA) and 2 smaller branches, one for LCCA and another for LAxA with a perfusion limb. The LAxA branch is passed through a tunnel to infraclavicular fossa and anastomosed to LAxA, and cardiopulmonary bypass is initiated through perfusion limb at 32 °C, followed by debranching of IA and LCCA. The rest of the operation is performed with complete cerebral perfusion. Following replacement of ascending aorta±root, cardiac reperfusion is started using a 16F root cannula connected to arterial line, and the rest of the operation is completed with the heart empty and beating with full antegrade cardiac perfusion. Distal arch anastomosis is performed clamp-on, allowing lower body perfusion via LSA. If a modified FET is planned, a 3-4 cm length of the rest of the aortic graft is invaginated and the folded edge is sutured to distal stump of arch. For modified FET, lower body perfusion is interrupted for 5 to 8 minutes to push the invaginated part of aortic graft to distal aorta to create a classic elephant trunk, and a standard TEVAR is deployed started 2 cm proximal of anastomosis, so the inner surface of anastomosis is covered by endograft. Following cannulation of the distal arch graft, perfusion of distal aorta and rewarming are restarted, and all three grafts are incorporated with full body perfusion to construct a neo-ascending aorta and arch.

Results: Between December 2018 and May 2022, 38 patients underwent TAR without operative mortality. Hospital mortality was %15.7 (6/38), and spinal cord ischemia and stroke were not encountered in surviving patients. The mean lower body interruption of perfusion time was 7.2± 2.8 minutes.

Conclusions: Usage of LAxA for arterial perfusion provides more complete cerebral and spinal cord perfusion with a potential to lower stroke and spinal cord injury following TAR with FET technique. Performing TAR with complete cerebral, cardiac, and lower body perfusion could decrease the need for hypothermia, protect cerebral autoregulation, and may lower mortality and morbidity following TAR. To perform a FET, only a short interruption of lower body circulation is sufficient to deploy an endograft, also improving hemostasis of distal anastomosis. Further studies with a higher number of patients are required to evaluate the efficiency of this novel technique.

Aortic Arch