Selective cerebral perfusion via right axillary artery direct cannulation for aortic arch surgery

Background: The risk of neurological complications is still a life-threatening event for patients undergoing proximal aortic arch or total aortic arch surgery. To prevent these complications, axillary artery cannulation and antegrade selective cerebral perfusion were utilized. We compared the effects of using hypothermic circulatory arrest (HCA) alone or with selective cerebral perfusion (SCP/AX) via right side axillary artery direct cannulation. Methods: 120 patients, mean age 61 12 years (range 26 - 80), underwent proximal aortic or total aortic arch replacement between 1999 and 2004; 46 were female. We retrospectively compared the results of the two patient groups comparable for preoperative risk factors: 71 pts were operated using HCA beginning in 1999 and 49 pts using HCA/SCP via axillary artery direct cannulation since 2002. The indication for surgery was an aortic aneurysm in 80 (67%) patients and aortic dissection in 36 (30%) patients. The groups were well matched with regard to median age (60 vs. 62 yrs), urgency (emergent/urgent 36 vs. 44%; elective 64 vs. 65%), and several other known risk factors (p = ns). Results: Overall in-hospital mortality was 13%: 10% with HCA vs. 6% with SCP/AX. Permanent neurological dysfunction occurred in 10% with HCA vs. 6% with SCP/AX. Transient neurological dysfunction (TND) in patients surviving without stroke was lower with SCP/AX (10%) than with HCA (17%) (p = ns). Mean duration of HCA was 28 +/- 12 min when isolated HCA was used, and significantly shorter with 21 6 min when the combination of SCP/AX (p = 0.03) was used. Mean duration of CPB was 202 55 min with HCA vs. 192 50 min with SCP/AX (p = ns). Comparison of the groups who had comparable preoperative risk factors showed a trend towards lower in-hospital mortality, stroke and TND rates, a significant reduction in cardiac (p = 0.034), infectious (p = 0.025) and bleeding complications (p = 0.04) in SCP/AX compared with HCA, as well as a significantly shorter duration of hospitalization (p = 0.046) and shorter ICU stay (p = ns). Conclusion: Our results suggest that HCA/SCP is superior to HCA alone for preventing cerebral injury during operations on the aortic arch. By reducing embolic risk, as well as the duration of HCA, SCP with axillary artery direct cannulation may be the optimal technique for averting cerebral events, reducing complications, and shortening hospital stays following aortic arch repair.