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Head-First Approach Streamlines Aortic Arch Replacement in Aneurysm and Dissection
Bo Chang B. Wu1, Nicolas Chanes1, Adam M. Carroll1, *Muhammad Aftab2, *T. Brett Reece2
1Surgery, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, Colorado, United States, 2Cardiothoracic Surgery, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, Colorado, United States
Background:
The head-first graft technique has emerged to reduce neurological complications in aortic surgery. We have utilized this method with modifications for total arch with frozen elephant trunk and zone 2 arch replacement since 2020. We aimed to evaluate the operative performance and postoperative outcomes of this approach.
Methods:
We reviewed adult patients undergoing aortic surgery for aneurysm or dissection using a head-first graft from August 2020 to March 2024 from a single-institution database. Patient perioperative variables were analyzed. Continuous and categorical variables were evaluated using the Mann-Whitney U test and Fisher's Exact test, respectively. Sub-analysis was performed on elective operations. Statistical analysis was conducted using custom-built Python and R scripts.
Results:
119 patients (52 aneurysm, 67 dissection) were identified. Aneurysm patients were older (62.7 ± 13.9 vs. 54.4 ± 15.3 years, p<0.001) with fewer urgent/emergent cases (7.7% vs. 67.2%, p<0.001). Preoperative WBC counts were higher in the dissection group (p<0.001).
Dissection patients had longer cerebral perfusion (23.4 ± 10.9 vs. 16.1 ± 6.3 mins, p<0.001), circulatory arrest (23.1 ± 11.3 vs. 16.3 ± 6.3 mins, p<0.001), cardiopulmonary bypass (202.6 ± 70.8 vs. 171.4 ± 46.6 mins, p<0.001), and cross-clamp times (96.1 ± 56.3 vs. 74.6 ± 37.8 mins, p=0.038), but fewer redo-sternotomies (29.9% vs. 67.3%, p<0.001).
Postoperative outcomes showed higher renal failure (20.9% vs. 3.8%, p=0.042), 30-day mortality (22.4% vs. 4.7%, p=0.044), and longer intubation time (2.7 ± 4.0 vs. 1.0 ± 1.6 days, p=0.002) in the dissection group with similar stroke incidence (p=0.658).
In the elective subgroup (n=70), dissection patients were younger (53.2 ± 15.8 vs. 62.8 ± 14.4 years, p=0.006) with longer cerebral perfusion (19.7 ± 6.71 vs. 15.8 ± 6.3 mins, p=0.017) and circulatory arrest times (19.7 ± 6.7 vs. 16.0 ± 6.3 mins, p=0.026), but there were no differences in preoperative labs, comorbidities, and postoperative outcomes.
Conclusions:
Patients undergoing the head-first graft technique for dissection presented more urgently and had worse perioperative outcomes, but similar stroke rates compared to aneurysm patients. Elective cases showed no difference in stroke or other postoperative outcomes between the two cohorts. Head-first approach for arch replacement facilitates timely reconstruction with shorter circulatory arrest without increasing stroke risk.
Table 1. Baseline demographic and periopeartive characteristics among patients who received repair using a Head-first graft for aortic aneuryssm or dissection.
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