Introduction of the Novel Warm Arch Repair Strategy

Various surgical techniques have been used for aortic arch repair, and hypothermic circulatory arrest with adjunctive cerebral protection strategy is the standard practice today. However, morbidity and mortality remain significant for both non-dissection and dissection pathologies. This video presents a streamlined approach for aortic arch repair that eliminates the need for hypothermic circulatory arrest, axillary femoral cutdown, or specialized equipment.

The standard setup involves right radial and femoral arterial lines, near-infrared spectroscopy (NIRS), sternotomy, and cardiopulmonary bypass with arch cannulation. Under normothermia without circulatory arrest, antegrade cerebral perfusion (ACP) is delivered through the innominate artery via a punctured aortic root needle cannula or a balloon-tipped catheter inserted from the ostium. Zone 1, for hemiarch or zone 1 arch repair, or zone 2, for zone 2 arch repair, were cross clamped using commercially available clamps with a flexible shaft.

The case demonstrated in this video is that of a sixty-four-year-old man with history of two open heart surgeries, including heart transplant thirteen years prior. The patient presented with two enlarging aortic aneurysms at the distal ascending aorta and mid aortic arch. A third-time redo hemiarch repair using the warm arch technique was performed. The skin-to-skin operative time, cardiopulmonary bypass, aortic cross clamp, and ACP time were 131 minutes, 65 minutes, 47 minutes, and 11 minutes, respectively. The patient was discharged home on the third postoperative day without complications.

In summary, the streamlined warm aortic arch repair using readily available off-the-shelf tools eliminates the need for axillary femoral cutdown, intrathoracic innominate artery graft sewing, or cooling and rewarming time for hypothermic circulatory arrest. The author’s team has performed warm arch repair procedures in 75 patients so far, including 21 patients with acute type A aortic dissection. This approach possibly results in shorter procedure times, avoidance of complications related to hypothermic circulatory arrest, and remarkable cost-saving. For non-DeBakey type 1 aortic dissection pathologies, the majority of hemiarch and selected partial arch repairs can be safely performed using this technique. Exclusion criteria for this technique include a porcelain aorta and selected DeBakey type 1 aortic dissection.

Reference(s)

assar AS, Vallabhajosyula P, Bavaria JE, Gutsche J, Desai ND, Williams ML, Milewski RK, Hargrove WC, Szeto WY. Direct innominate artery cannulation: An alternate technique for antegrade cerebral perfusion during aortic hemiarch reconstruction. J Thorac Cardiovasc Surg. 2016 Apr;151(4):1073-8.