Modified Arch First Technique for Total Arch Replacement using Hypothermic Circulatory Arrest and Retrograde Cerebral Perfusion

Patients and methods: From 1998 to 2007, there were 90 consecutive patients who underwent the modified arch first technique for total arch replacement using hypothermic circulatory arrest (HCA) and retrograde cerebral perfusion (RCP). There were 63 true aneurysms, and 13 chronic and 11 acute Stanford type A dissections. Sixteen cases were operated on as emergencies. Results: The mean operation time was approximately 6.5 hr. The mean cardiopulmonary bypass time exceeded 3.5 hr as a result of applying HCA, with an average lowest esophageal temperature of 19.2 degrees C. The mean HCA time with RCP was 31.2 +/- 8.6 min. However, the lower body ischemic time was 80 min because of double segment distal anastomoses were performed. The cardiac ischemic time was nearly 2 hr. There were 4 hospital deaths. Nine patients (10%) suffered from stroke. Reversible ischemic neurological deficit was complicated during the operation in six cases (7%). Conclusions: A recently refined arch first technique under HCA and RCP is still developing, but some refinements definitely contribute to better clinical outcomes. According to current information, the use of RCP for cerebral protection during HCA is safe when flow rates and central venous pressures are maintained at relatively low levels. (190 words)