1. Con: DHCA is not required for aortic arch surgery ACTA Lecture Series: October 5, Alexander J Gregory MD, FRCPC CT Anesthesia Fellow Department of Anesthesiology and Critical Care
University of Pennsylvania
Hospital System

3. Definitions Circulatory arrest Antegrade cerebral perfusion (ACP)
Hypothermia
Neurologic deficit (PND vs TND)

5. ACP Techniques CPB cannula = UACP cannula CPB cannula + UACP or BACP
Direct cannulation vs. graft vs. balloon
Spinal cord perfusion
Lower body and viscera perfusion

7. ACP Disadvantages Embolization Dissection
Variable cerebral circulation (Circle of Willis)
Increased complexity
Surgical field clutter
Increased cost

9. Urbanski
Zierer
Total
Non Type A
< 30 mins
30-60 mins
> 60 mins
Mortality
0.9 %
5 %
4 %
3 %
8 %
11 %
PND
2 %
TND
2.3 %
Paraplegia
0 %
0.3 %
----
ARF
1.5 %
6 %
ALF

10. Includes Acute Type-A Dissections
Urbanski
Zierer
Total
Non Type A
< 30 mins
30-60 mins
> 60 mins
Mortality
0.9 %
5 %
4 %
3 %
8 %
11 %
PND
2 %
TND
2.3 %
Paraplegia
0 %
0.3 %
----
ARF
1.5 %
6 %
ALF
Includes Acute Type-A Dissections

11. Excluding Acute Type-A Dissections
Urbanski
Zierer
Total
Non Type A
< 30 mins
30-60 mins
> 60 mins
Mortality
0.9 %
5 %
4 %
3 % 4%
0 %
PND
2 %
TND
2.3 %
Paraplegia
0.3 %
----
ARF
1.5 %
8 %
ALF
Excluding Acute Type-A Dissections

12. ACP Disadvantages ? Local axillary neuro = 5/655 (0.8%)
Vascular complications = 0/1002 (0%)
Ax. post-op compartment synd. = 0/655 (0%)
Ax. post-op malperfusion = 0/655 (0%)
Carotid hyperperfusion = 0/347 (0%)

14. Disadvantages of Hypothermia
Increased CPB time
Coagulopathy
Increased vascular resistance
Left shift of Oxy-Hgb curve
Impaired cerebral autoregulation
Impaired immune system
Multi-organ dysfunction
Rewarming injury

16. Moderate ACP vs DHCA +/- RCP (Misfeld 2012)
ACP + mod
DHCA +/- RCP
p-value
Mortality
9 %
11 %
0.1
PND
14 %
< 0.05
TND
16%
0.5
Respiratoty failure
17 %
25 %
ARF
15 %
0.2
Low CO syndrome
7 %
4 %
0.3
Sepsis
5 %
GI complication
8 %

18. Mild ACP vs Deep ACP (Watanabe 2011)
ACP + mild
ACP + deep
p-value
Mortality
0 % NS
CVA
19 %
< 0.05
CPB (min)
128
197
< 0.001
OR (min)
303
431
<0.001
ABT (mL)
682
1490
< 0.01
Extubation (hrs) 24 88
Hospital LOS (d) 28 42

20. Mild ACP vs Moderate ACP (Kaneda 2005)
ACP + mild
ACP + mod
p-value
Mortality
10 % NS
PND
5 %
CPB (min)
146
217
< 0.01
OR (min)
345
510
<0.01
ABT (mL)
1724
3051
< 0.05
Intubation (d)
1.9
4.9
ICU LOS (d)
4.6
8.5

21. Mild ACP vs Moderate ACP (Numata 2012***)
ACP + mild
ACP + mod
p-value
Mortality
6 %
> 0.99
PND
10 %
0.39
TND
CPB (min)
164
188
<0.05
ARF
4 %
15 %
< 0.05
A Fib
16 %
35 %
< 0.01
MV > 3 days
7 %
18 %
Re-exploration
5 %
11 %
0.15
GI bleed
1 %
0.1

24. Future Direction CA < 30 minutes: DHCA vs ACP+mild
CA minutes: RCP vs ACP
CA > 45 minutes: ACP + mild vs ACP + deep
ACP techniques (ex: UACP vs BACP)
Lower body perfusion techniques