Surgical procedure and perfusion technique
Generally, we select the perfusion technique depending on the patient’s
age and aortic arch repair complexity. CCMSP at 28°C is our preferred
technique for all extensive aortic arch reconstruction in neonates. DHCA
is rarely performed, rather reserved for more complex repairs.
Whole-body perfusion at normothermia without circulatory arrest,
indicated for older children, is achieved by perfusing the brain via the
BCA and the body via femoral artery cannulation. According to the
literature, the perfusion techniques in pediatric aortic arch surgery
vary widely and the debate is never ending, with no established
consensus as of yet. MHCA with ACP is likely to provide improved brain
protection with fewer neurological complications (2)(3)(9) though
several authors were unable to clearly demonstrate ACP’s superiority
over DHCA in terms of neurocognitive complications. In a randomized
controlled trial comparing DHCA versus ACP, Algra and colleagues did not
detect any between-group difference in new neurological injuries on
immediate post-operative MRI or in neurocognitive or motor outcomes at
24 months (10). Using the STS database with 4,523 American patients,
Meyer and colleagues reported ACP to have increasingly become the new
trend, used 43% of times versus 32% for DHCA (11). Approximately 16%
of centers employ a mixed approach comprising both a complete
circulatory arrest and an ACP during the same procedure.