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Use of Subclavian-Carotid Bypass and Thoracic Stent Grafting to Minimize Cerebral Ischemia in Total Aortic Arch Reconstructions
Steve Xydas1, Benjamin Wei2, Hiroo Takayama1, Mark J. Russo1, Craig R. Smith1, Matthew D. Bacchetta1, Allan Stewart1; 1NY Presbyterian Hospital-Columbia, Division of Cardiothoracic Surgery, New York, NY; 2NY Presbyterian Hospital-Columbia, Department of Surgery, New York, NY
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Objective: Total aortic arch replacement (TAAR) typically requires either a period of hypothermic circulatory arrest (HCA) and/or the use of antegrade selective cerebral perfusion (SCP), carrying the risks of cerebral ischemia. We recently introduced the use of left subclavian-carotid bypass (SCB) prior to TAAR with staged thoracic stent grafting to achieve total arch reconstruction with relatively short periods of SCP. We compared our institutional experience of TAAR with and without SCB.
Methods: From July 2004 to August 2008, 329 patients at our institution underwent ascending aorta or arch replacements. Of these, 34 patients (64% male, 36% female; mean age 66 years) underwent TAAR. TAAR was performed with cannulation of the right axillary artery to establish SCP after cooling to 28 degrees C and/or HCA at 18 degrees C. In 2008, we began performing left SCB prior to a debranching procedure of the aortic arch involving use of a bifurcated aortic graft with aorta to innominate and aorta to left carotid artery bypass. These patients then underwent staged thoracic aortic stenting with deployment into the aortic graft to complete arch reconstruction. 28 patients received TAAR without left SCB (Group I). 6 patients received TAAR with left SCB and aortic stent grafting (Group II).
Results: Patient characteristics are shown in Table 1. The mean duration of SCB time in Group I was 34 minutes, compared to 16 minutes in Group II (p=0.007). 50% of the patients in Group I required HCA, compared to 0% in group II. The mean cardiopulmonary bypass (218 min vs 154 min, p=0.03) and aortic crossclamp times (109 min vs 76 min, p=0.04) were longer in Group I than Group II. The incidence of neurological complications, defined as stroke or spinal cord ischemia within 48 hours of surgery, was 18% in Group I (5/28), compared to 0% (0/6) in Group II (p=0.28). There were no significant differences in the mortality rate or the length of ICU or hospital stay between Groups I and II.
Conclusion: Left SCB prior to TAAR with staged thoracic stent grafting to achieve total arch reconstruction was associated with a significant decrease in the duration of SCP and eliminated the need for HCA. This technique may prove to decrease the risk of neurological complications associated with TAAR and provide a viable hybrid approach to patients with aortic arch aneurysms.

Table 1. Comparison of preoperative, intraoperative, and postoperative variables for patients receiving TAAR only (Group 1) versus TAAR with subclavian-carotid bypass and thoracic stent grafting (Group 2).
Group I (n=28) Group II (n=6) p value
Preoperative
Age (mean), years 69 65 0.57
Male, n (%) 17 (61) 5 (83) 0.39
Female, n (%) 11 (39) 1 (17) 0.39
Hypertension, n (%) 25 (89) 4 (67) 0.21
Coronary artery disease, n (%) 11 (39) 3 (50) 0.67
Diabetes mellitus, n (%) 6 (21) 2 (17) 0.79
Atrial fibrillation, n (%) 3 (11) 2 (33) 0.20
Previous stroke, n (%) 2 (7) 2 (17) 0.45
COPD, n (%) 4 (14) 0 (0) 0.94
Congestive heart failure, n (%) 3 (11) 0 (0) 0.42
Reoperative surgery, n (%) 6 (21) 0 (0) 0.22
Elective surgery, n (%) 14 (50) 2 (33) 0.67
Operative
Concomitant CABG, n (%) 6 (21) 0 (0) 0.22
Concomitant valve surgery, n (%) 3 (11) 3 (50) 0.05
Descending thoracic stent graft, n (%) 4 (14) 6 (100) n/a
Use of HCA, n (%) 14 (50) 0 (0) n/a
HCA time (mean), min 19 n/a n/a
Use of SCP, n (%) 14 (50) 6 (100) n/a
SCP time (mean), min 34 16 0.007
CPB time (mean), min 218 154 0.03
Aortic cross-clamp time (mean), min 109 76 0.04
Packed red blood cells (mean), units 3.1 3.8 0.65
Postoperative
ICU stay (median), days 3.5 3 0.31
Hospital stay (median), days 10 10 0.49
Stroke, n (%) 3 (11) 0 (0) 0.42
Spinal cord ischemia, n (%) 2 (7) 0 (0) 0.51
Neurological complications (stroke or spinal cord ischemia), n (%) 5 (18) 0 (0) 0.28
Death, n (%) 5 (18) 1 (17) 0.89

CABG - coronary artery bypass graft, CPB - cardiopulmonary bypass, HCA - hypothermic circulatory arrest, SCP - selective cerebral perfusion, n/a - not applicable
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