Cerebral Protection With Deep Hypothermic Circulatory Arrest During Total Arch Replacement Using the Arch-First Technique for Acute Aortic Dissection

Objectives: Stroke remains a serious complication after total arch replacement (TAR). To prevent this, deep hypothermia is commonly employed during TAR. We evaluated the effectiveness of cerebral protection using deep hypothermic circulatory arrest (DHCA) during TAR with the arch-first technique, focusing particularly on patients with acute aortic dissection (AAD). Methods: This retrospective study included 109 consecutive patients with AAD who underwent emergency TAR using the arch-first technique under DHCA, and 147 patients with non-ruptured aneurysm who underwent scheduled TAR using the same technique between October 2009 and July 2022. We reviewed these patients for major adverse events, including stroke and 30-day mortality after surgery. We also analyzed the impact of clinical variables and anatomical features on the occurrence of newly developed stroke after TAR in patients with AAD. Results: A newly developed stroke after TAR occurred in 11 (10.1%) patients with AAD. These were attributed to embolism in eight patients, malperfusion in two patients (including one who had been comatose), and low output syndrome in one patient. A stroke occurred in 3 (2.0%) patients with aneurysm, all due to embolism (P = 0.005). The DHCA time was 37 +/- 7 minutes for patients with AAD and 36 +/- 6 minutes for patients with aneurysm (P = 0.122). The 30-day mortality rate was 10 (9.2%) for patients with AAD and 2 (1.4%) for patients with aneurysm (P = 0.003). In our multivariable analysis, arch vessel dissection with a patent false lumen (double-barreled dissection) was the only significant predictor of newly developed stroke after TAR for AAD (odds ratio, 33.02; P < 0.001). Conclusions: Patients with aneurysm undergoing TAR using the arch-first technique under DHCA experienced significantly better outcomes, in terms of newly developed stroke and 30-day mortality, than those with AAD. Cerebral protection with DHCA during TAR using the arch-first technique continues to be a viable option. Newly developed stroke in patients undergoing TAR for AAD appears to be associated with air emboli deriving from the residual dissection with a patent false lumen in the repaired arch vessels.