1. Without Deep Hypothermia
Aortic Symposium 2010
AATS
Branch First Aortic Arch Repair
Without Deep Hypothermia
Or Circulatory Arrest
George Matalanis, Rhiannon Koirala
Austin Medical Centre
Melbourne, Australia

2. Problems with Current Techniques
Circulatory arrest (CA)
Maximum “safe” period
Opportunity for air/debris embolism
Deep hypothermia (DH)
Prolonged bypass
Coagulopathy
Retrograde Cerebral perfusion
Negligible nutritive flow
Unilateral Antegrade Perfusion
Contralateral hypoperfusion
Ipsilateral hyperperfusion
Bilateral Antegrade Perfusion
Direct cannulation risks
View obstruction

3. Collateral Anatomy NOT like Carotid Endarterectomy
Without shunt complete reliance on CIRCLE OF WILLIS
15% inadequate ICA stump pressure
Even then Stroke risk < 3% if clamp time < min

4. Collaterals Available in Individual Proximal Arch Branch Clamping
Subclavian
Right
carotid
Left
carotid
Carotid
Upper body
External
carotid
Internal
carotid
Lower body

5. Cannulation and bypass
Dual upper and lower body inflow
 pressure gradients
Maintenance of body perfusion after innominate clamping
Direct Ascending Aorta - alternative in PVD/thoraco- abdominal atheroma

6. Reconstruction Sequence

7. Patients 30 cases: Jul 2005- Oct 2009 Male : Female = 19:11
Age: 62 (28-85)
Smoking: 57%
Hypertension: 63%
CVD: 23%
CAD: 30%
Elective
18 (60%)
Urgent/Emergent
12 (40%)
Type A dissection
16 (53%)
Re-operation
4 (13%)

8. Concomitant Procedures
Aortic Root:19 (63%)
Valve sparing: 14 (74%)
David: 3
Other valve sparing: 11
Bentall’s: 5 (26%)
Mechanical: 3
Tissue: 2
Separate AVR: 2 (7%)
Elephant Trunk: 4 (13%)
Regular: 2
Frozen: 2
CABG: 6 (20%)

9. Early outcomes Mortality: 1 (3.3%) Neurological Dysfunction: 4 (13%)
85 y.o, late presenting Ac Type A
Neurological Dysfunction: 4 (13%)
All focal/embolic:
Amourosis Fugax
Hemianopia,
Hemiparesis,
Dysphasia.
Complete recovery: 3
Residual deficit: 1 (hemianopia)

10. Other Morbidity Re-exploration: 3 (10%)
Mechanical Cardiac support: 1*(3.3%)
Renal support: 1* (3.3%)
Tracheostomy: 1 (3.3%)
Sternal infection: nil
* mortality

11. Benefits Ventilation < 24 hrs: 12 (40%)
ICU stay < 2 days: 14 (47%)
Hospital stay ≤ 7 days: 10 (33%)
NO TRANSFUSION: 8 (26.7%)
2 of these were re-operative cases

12. Conclusions Branch First aortic arch repair is a safe procedure :
3.3% Mortality
3.3% permanent Stroke
Applicable to urgent and complex cases
Haemostatic
27% no blood/product transfusion
Better visceral organ protection
1.3% CVVH
Allows complete and unhurried repair
Avoid late deaths from undertreated aortic segments
Avoid difficult redo for persistent/recurrent aortic pathology