Surgical technique
Surgery was performed via median sternotomy or left lateral thoracotomy.
The selection of one of the arterial accesses for cardiopulmonary bypass
(CPB) (ascending aorta vs aortic arch vs brachiocephalic trunk vs right
or left common carotid artery vs femoral artery) depended on the extent
of aneurysm and/or dissection, the planned extent of the repair, as well
as the cerebral protection method, and was left to the discretion of the
operating surgeon. The right atrium was used for blood drainage for CPB.
Depending on the central nervous system protection technique implemented
during circulatory arrest, the patient was cooled to 17 degrees C (deep
hypothermic circulatory arrest, DHCA) or 26 degrees C when selective
brain perfusion was used. The patients’ body temperature was measured
simultaneously in the esophagus and in the bladder. One of the 3 types
of cardioplegic regimens was used: cold del Nido cardioplegic solution,
cold blood cardioplegic solution (4:1 ratio) and cold miniplegia.
One of the following techniques was used for central nervous system
protection:
- deep hypothermic circulatory arrest (DHCA) [4]
- moderate hypothermia with circulatory arrest and selective antegrade
cerebral perfusion (SACP) with monitoring of cerebral oxygenation
(INVOS 5100C, Medtronic, Dublin, Ireland) [5]
- in surgeries involving the descending aorta the cerebrospinal fluid
drainage with monitoring of cerebrospinal fluid pressure was performed
[6].
The patients’ arterial blood pressure was monitored in both left and
right radial arteries and in one of the femoral arteries.
The scope of aortic arch surgeries (open arch surgery):
- Partial replacement of the aortic arch (hemiarch) – involving the
replacement of the minor curvature of the aortic arch [7] (Fig.
2A).
- total arch replacement (TAR) involving aortic arch replacement with
concomitant re-implantation of arch vessels en-bloc or with separate
anastomoses [8] (Fig. 2B-C).
- implantation of a dacron patch into the base of the saccular aneurysm
(Fig. 2D).
Distal anastomosis with the descending aorta was performed end-to-end or
in case of the co-existing descending aorta aneurysm with the use of the
elephant trunk (ET) [9] or frozen elephant trunk (FET) technique
[10]. The E-vita OPEN PLUS (Jotec Inc., Hechingen, Germany) system
was used for the frozen elephant trunk procedures (Figure 1C).
The additional procedures performed on the aorta included:
supracoronary ascending aorta replacement for ascending aorta
aneurysm,
aortic root replacement with coronary arteries re-implantation
(Bentall de Bono technique) or valve sparing aortic root replacement
(David method or Yacoub method) [11] for aortic root aneurysm.
Other concomitant procedures performed included: aortic valve
replacement/aortic valve repair [12], mitral valve
replacement/mitral valve repair, tricuspid valve repair, coronary artery
bypass grafting.