1. Comprehensive Cerebral Protection During Operations Involving the Aortic Arch Vincent Gaudiani, MD, Paul Shuttleworth, CCP Luis Castro, MD, Audrey Fisher, MPH, Conrad Vial, MD Sequoia Hospital, Redwood City, California May 19, 2006

2. Comprehensive Cerebral Perfusion Circuit 1.Separate Arterial Cannulation of the Cerebral & Systemic Circulation 2.Separate Heat Exchangers for Each Circulation – allows for differential temperature management; no active re-warming of the brain beyond 32-33  C 3.Separate Clamping of the Two Circulations – at the end of the case, discontinue systemic before unclamping and discontinuing cerebral perfusion Key Elements:

3. Results (2002-2005) Factor All Cases (n=71) Type A Dissection(n=19)ArchAneurysm(n=22) Grade IV/ Calcific(n=30) Perioperative Stroke 1.4% (1) 5.3% (1) 0% (0) Operative Mortality 9.9% (7) 5.3% (1) 4.5% (1) 16.7% (5) Median Postop LOS (days) 10.010.09.09.5 Grade IV/Calcific Procedures Included: 26 AVRs 7 Ao Root Recon 5 Asc Ao Recon 2 Arch Recon 17 CABs 3 MVRs

4. Conclusions/Implications Among these 71 patients, none died of cerebral complications, and only one suffered stroke. Comprehensive Cerebral Perfusion (CCP) provided excellent cerebral protection and reasonable outcomes in these high-risk aortic arch cases. Among these 71 patients, none died of cerebral complications, and only one suffered stroke. Comprehensive Cerebral Perfusion (CCP) provided excellent cerebral protection and reasonable outcomes in these high-risk aortic arch cases. We recommend CCP as an alternative strategy to profound hypothermia and circulatory arrest for aortic dissection and arch aneurysm operations. We recommend CCP as an alternative strategy to profound hypothermia and circulatory arrest for aortic dissection and arch aneurysm operations. We also recommend this technique for cases that exhibit Grade IV mobile arch atherosclerosis (by intraoperative echocardiography) and/or severe aortic calcification. We also recommend this technique for cases that exhibit Grade IV mobile arch atherosclerosis (by intraoperative echocardiography) and/or severe aortic calcification.