Branch First Arch Replacement in the management of Acute and Chronic Aortic Pathology. A New Zealand Perspective.

P0071 

Abstract Submission 

Nikhil Chandra (1), Kamaraj Radhakrishnan (1), Sean Galvin (2)

(1) Wellington Regional Hospital, Wellington, New Zealand, (2) Victoria University / University Otago, Wellington, New Zealand

Nikhil Chandra    -  Contact Me
Wellington Regional Hospital

Kamaraj Radhakrishnan    -  Contact Me
Wellington Regional Hospital

Sean Galvin    -  Contact Me
Victoria University / University Otago

Nikhil Chandra    -  Contact Me
N/A

Objective: To evaluate whether branch first aortic arch replacement leads to improved outcomes in patients undergoing emergency or elective surgery for acute or chronic aortic pathology. This technique avoids total body circulatory arrest and profound hypothermia, resulting in excellent long-term survival, lower neurological and other end organ complications/dysfunction.
Methods: A single surgeon experience of branch first aortic arch replacement from December 2014 to December 2023 at a cardiothoracic unit in Wellington, New Zealand. Branch first arch replacement was introduced in Wellington in 2014. Total of 84 cases was performed by one surgeon in this period. The first four years a total of 62 patients underwent branch first aortic arch replacement in the unit with one surgeon performing 49 of those. The next 5 years saw the unit performing 78 branch first cases with one surgeon performing 35 of those. This highlights the safety and reproducibility of the technique as it was widely adopted in the unit by other surgeons. Each case is performed in an identical manner with establishing central or peripheral CPB and performing sequential disconnection and reconstruction of arch vessels from innominate artery to the left subclavian artery using a modified trifurcation dacron graft with a perfusing side arm port which is used for antegrade cerebral perfusion. During this sequential debranching, perfusion to the heart and distal organs is maintained. Once the proximal and distal aortic anastomosis is completed, the common stem of the trifurcation graft is anastomosed to the neo ascending aorta. In this series, the mean age was 61.9 (range 19- 84 years). Fourty five cases (53.6%) were of an urgent/emergency status for acute aortic syndrome, the remaining cases were performed for enlarging aneurysms or for chronic type B dissections that required debranching of the arch to allow for a safe TEVAR landing zone. Fifteen patients (17.8%) underwent a redo operation.
Results: There were six mortalities (7.1%), all in the emergency group with no elective mortality. 2 patients (2.3%) had a post operative stroke. Six patients (7.1%) returned to theatre for either bleeding, wound closure or pleural space wash out. One patient (1.1%) required an intra-aortic balloon pump and six patients (7.1%) required haemo-filtration for renal support.
Conclusion: The branch first aortic arch replacement enables us to treat the full extent of the diseased aorta. By maintaining continuous antegrade cerebral perfusion, shortening the distal body circulatory arrest time, cardiac ischaemic time and by avoiding profound hypothermia, the patient outcomes are close to being comparable to results of ascending aorta and root surgery. It has excellent long term outcomes and is a durable, reproducible and safe technique.

Aortic Surgery Forum (Basic Aortic Research, Venue for Residents, Fellows, Junior Attendings)