Adult: Aorta
Aortic arch isolation to reduce cerebral embolic risk during replacement of the atherosclerotic aortic arch

https://doi.org/10.1016/j.jtcvs.2022.04.018Get rights and content

Abstract

Objective

To analyze the efficacy of isolating the upper body circulation from the lower body (isolation technique) in reducing the risk of embolic stroke during cardiopulmonary bypass in patients with severe atherosclerosis undergoing aortic arch surgery.

Methods

Between 2006 and 2019, 156 patients with severe atherosclerosis undergoing total arch replacement were enrolled. Since 2017, the right axillary or innominate artery and ascending aorta were both cannulated before cardiopulmonary bypass in the isolation group (n = 30). The left common carotid artery was clamped and inserted with a 13-Fr balloon perfusion catheter. The innominate artery was clamped in succession and cardiopulmonary bypass was instituted, establishing a parallel noncommunicating circulation for the upper and lower body. Patients without atherosclerosis that were not considered at high risk of embolic complications were excluded. The no-isolation group was drawn from historically matched control patients undergoing total arch replacement.

Results

The permanent stroke rate in the isolation and no-isolation groups were 3.3% (n = 1) and 15.9% (n = 15.9), respectively. After inverse-probability-of-treatment-weighting adjustment, the early mortality (P = .043), stroke (P = .044), and composite of early mortality or stroke (P = .005) rates were significantly lower in the isolation group. The logistic regression analysis after inverse-probability-of-treatment-weighting risk adjustment showed a significantly reduced composite risk of early death and stroke in the isolation group (odds ratio, 0.09; 95% confidence interval, 0.01-0.70; P = .023).

Conclusions

The isolation technique was associated with a significant reduction in early postoperative embolic stroke and mortality risks in patients with severe aortic atherosclerosis undergoing total arch replacement.

Section snippets

Patient Selection

The aortic arch isolation technique was performed in 30 patients undergoing total arch replacement for severe degenerative atherosclerotic aortic arch aneurysm (shaggy aorta) between November 2017 and September 2019 at our institution. The “arch-isolation technique” was selectively employed in patients with shaggy atherosclerotic aortic lesions in the ascending aorta and or arch and proximal descending aorta. The definition of shaggy aorta was based on that described by Hollier and colleagues7

Results

There were 126 patients in the no-isolation group and 30 in the isolation group. The nonadjusted baseline characteristics for the major preoperative risk factors including diabetes mellitus, hypertension, coronary disease, chronic kidney disease, and cerebrovascular disease showed no significant inter-group differences (Table 1, left column). Although the arch-isolation patients were older than the no-isolation group (P = .012), no significant intergroup differences in the baseline

Discussion

The isolation technique is a surgical concept of a technical strategy designed to reduce or ideally eliminate the risk of embolic stroke in patients with advanced shaggy mobile atherosclerosis. Aortic surgery, especially aortic arch surgery, often carries a high risk of embolic stroke and major downstream embolic complications.8 Therefore, in some cases adjunctive strategies, such as flushing and suction removal of displaced aortic debris in the descending aorta after the distal anastomosis

Conclusions

The present study supports the previous observational studies supporting the use of the isolation technique in these high-risk patients. The isolation technique may be an important consideration in the present era of a growing aging global population with severe atherosclerosis. Accordingly, further studies aimed at acquiring a better understanding of the implications of these surgical strategies may be warranted.

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