Total arch replacement with selective antegrade cerebral perfusion and mild hypothermic circulatory arrest.

This article describes the surgical techniques demonstrated in our video, “Total arch replacement (TAR) with selective antegrade cerebral perfusion (SACP) and mild hypothermic circulatory arrest” (Video 1). The aortic arch is the most common location for the development of aortic aneurysms. These aneurysms are often located close to the brachiocephalic vessels, and atheromatous plaque and thrombus are often present both in the aneurysm and in the nearby aorta. In addition, the brachiocephalic branches, especially the left subclavian artery, frequently have atheromatous plaque at the orifices. Despite recent progress in endovascular treatments, mural thrombus and atherosclerotic debris in the aortic arch are frequently problematic. Therefore, endovascular repair cannot be considered as the first-line intervention for arch aneurysm without establishing secure preventive measures against atheroembolism caused by catheterization. The open replacement of the whole aortic arch with brachiocephalic vessel reconstruction using prosthetic grafts remains the gold standard procedure for the management of this condition. Historically, open aortic arch surgery for aortic arch aneurysm has been invasive. We believe that four factors make open arch repair difficult: (I) possible brain injury due to inadequate protection; (II) a deep, narrow operative field in the distal aorta and the left subclavian artery; (III) hemorrhage and transfusion; and (IV) possible myocardial damage due to prolonged ischemia. Therefore, we have used hypothermic circulatory arrest with SACP rather than other brain protective methods, and developed a method to optimize the operative field. Our procedure for arch aneurysm is simple and standardized. We use systemic cooling until 25 to 28 °C at tympanic membrane temperature, followed by SACP with balloon-tipped catheters and myocardial protection by intermittent retrograde blood cardioplegia. Anastomoses are sequentially constructed at the distal arch, the proximal root, the left subclavian artery, the left carotid artery, and the right brachiocephalic artery. Most of these procedures are routinely completed within 3 hours. Patients even over 80 years old can mobilise on the ward and resume oral diet on postoperative day one. Fast-tracked recovery is certainly achieved with this surgical procedure.