Does using both axillary arteries for arterial return during aortic arch surgery reduce the risk of neurovascular complications?

P0110 

Abstract Submission 

RAVI DE SILVA (1), Rushmi Purmessur (2), Morgan Quinn (3), Ismail Vokshi (3), Florian Falter (4), Shakil Farid (5)

(1) Royal Papworth Hospital NHS Foundation Trust, Leicester, Cambridgeshire, (2) Royal Papworth Hospital NHS Foundation Trust, Cambridge, Cambridgeshire, (3) Royal Papworth Hospital NHS Foundation Trust, Cambridge, NA, (4) Royal Papworth NHS Foundation Trust, Cambridge, NA, (5) Royal Papworth Hospital NHS Trust, Cambridge, NA

RAVI DE SILVA    -  Contact Me
Royal Papworth Hospital NHS Foundation Trust

Rushmi Purmessur    -  Contact Me
Royal Papworth Hospital NHS Foundation Trust

Morgan Quinn    -  Contact Me
Royal Papworth Hospital NHS Foundation Trust

Ismail Vokshi    -  Contact Me
Royal Papworth Hospital NHS Foundation Trust

Florian Falter    -  Contact Me
Royal Papworth NHS Foundation Trust

Shakil Farid    -  Contact Me
Royal Papworth Hospital NHS Trust

RAVI DE SILVA    -  Contact Me
Royal Papworth Hospital NHS Foundation Trust

Objectives
Aortic arch surgery is complex and associated with neurovascular complications. Cerebral protection and spinal cord preservation are vital parts of the operation, having significant bearing on the clinical outcome. Replacement of the arch with a Frozen Elephant Trunk (FET) procedure usually involves sequential anastomoses of the arch branches, of which the left subclavian artery is the most surgically inaccessible and often the most fragile. It is also intimately related to the recurrent laryngeal nerve (RLN). Incidences of RLN injury, permanent stroke and paraplegia following aortic arch surgery in adults have been reported to be as high as 25%, 20% and 7% respectively. The axillary artery is a continuation of the subclavian artery, branches of which include the vertebral and thyrocervical arteries. These supply the brain and spinal cord. We suggest that using both axillary arteries as arterial return for cardiopulmonary bypass (CPB) during aortic arch surgery will increase perfusion of the brain and spinal cord and reduce instrumentation in the proximity of the left recurrent laryngeal nerve, thereby reducing the complications previously described.
Methods
Electronic medical records were used to ascertain patient demographic and operative details and outcome data. Our surgical protocol starts with exposing both axillary arteries and then anastomosing a 10mm vascular graft to each. An arterial perfusion line from the bypass machine is connected to each of the grafts. After establishing venous return and CPB (perfusing both axillary arteries) the patient is cooled to a core temperature of 25 0C. At this temperature the left subclavian artery (LSA) is ligated proximally, and the other arch branches transected. The arch replacement proceeds with deployment of the FET prosthesis during a short period of lower body ischaemia, during which time perfusion of both axillary arteries continues. After anastomosing the FET to the aorta, lower body perfusion recommences using the arterial line supplying the left axillary artery. The graft attached to the left axillary is tunnelled through the second intercostal space and delivered into the mediastinum where it is easily anastomosed to the third branch of the FET prosthesis. Sequential anastomosis of the remaining arch branches continues with relative ease, and finally the proximal graft section of the FET is attached to the native aorta.
Results
We have performed 109 FET cases using the bilateral axillary artery approach as described. We have had one case of RLN palsy (0.9%), no cases of paraplegia and 12 cases of permanent stroke (11.0%).
Conclusions
In our series using both axillary arteries for perfusion, the incidence of RLN injury, permanent stroke and paraplegia are very low in comparison to other published large volume series. Additionally, the extra-anatomic bypass of the LSA is technically far easier than anastomosing directly to the LSA, especially in cases of acute aortic dissection when this vessel can be fragile. We advocate using bi-axillary arterial cannulation for CPB in FET surgery. Larger, multi-centre series or controlled trials are desirable to validate this technique.

Aortic Arch