Modified total arch replacement using a four-branched arch graft for acute type a aortic dissection with minimal brain and spinal cord ischemic time

Aim. This study aimed to evaluate the results of modified surgical strategies of total arch replacement using a four-branched arch graft, stented elephant trunk, and innovative organ protection method for acute type A aortic dissection. Methods. Between August 2011 and December 2011, 21 patients with acute type A aortic dissection underwent modified total arch replacement using the four-branched arch graft technique. All 21 patients had emergency surgery. Five patients had undergone previous aortic or cardiac surgery. The operations were stented elephant trunk implantation in 17 patients, ascending aorta replacement in 21 patients, coronary artery bypass grafting in four patients, Bentall operation in two patients, and aortic valve replacement in one patient. Twenty-one operations were performed under deep hypothermic extracorporeal circulation, modified selective cerebral perfusion, and end-organ and spinal cord protection for arch reconstruction. Results. There was two in-hospital deaths (9.5%). No persisting neurologic deficits or paraplegia occurred in 21 patients. Cardiopulmonary bypass time was 177.9+/-37.8 minutes. Myocardial ischemic time was 110.3+/-29.3 minutes. ICU time was 8.8+/-6.9 days and in-hospital duration was 28.7+/-13.7 days. Ventilation time varied from 9 hours to 21 days. A tracheotomy was necessary in four patients. Mean follow-up was 7.3+/-1.7 months and all patients are still alive. Conclusion. Modified total arch replacement using a four-branched arch graft with stented elephant trunk and innovative organ protection is a useful and safe alternative technique for the treatment of acute type A aortic dissection and the results are encouraging.