Objective: Despite advances in surgical techniques in the management of anesthesia and cardiopulmonary bypass surgery, brain complications after aortic arch surgery remain an important factor in morbidity and mortality because most patients are elderly and have severe comorbidities. The prevention of cerebral embolism is important during the repair of an aortic arch aneurysm. However, cerebral embolism can occur in both cannulation sites due to atherosclerotic changes in the ascending aorta near the arch aneurysm, or retrograde perfusion via the femoral artery. We describe our strategy for cerebral protection during aortic arch surgery in patients with aortic thrombus and atheroma.
Patients and methods: From April 2005 through December 2010, we performed total replacement of the aortic arch in 59 consecutive patients with aortic arch aneurysms in our hospital. Among these, 13 (22%) had thick atheromas in the arch aneurysm, and severe atherosclerotic changes from the abdominal aorta to the femoral artery. We used various devices to prevent cerebral embolism. We initially anastomosed 8-mm grafts to the bilateral axillary arteries for systemic arterial cannulation, the left common carotid artery was directly punctured and cannulated, and then the left common carotid artery was clamped as soon as cardiopulmonary bypass was initiated. After deep hypothermic circulatory arrest was achieved, antegrade selective cerebral perfusion was established through the grafts anastomosed to the bilateral axillary arteries, and a perfusion cannula was placed directly into the left carotid artery. All 13 patients underwent total replacement of the aortic arch with the ascending or descending aorta, and 2 underwent concomitant coronary artery bypass grafting.
Results: The total operation, total cardiopulmonary bypass, cardiac ischemia, hypothermic circulatory arrest and selective cerebral perfusion durations were 633 ± 80, 210 ± 36, 145 ± 30, 53 ± 27 and 147 ± 50 minutes, respectively. Of the 13 patients, 2 died in hospital (hospital mortality, 15.4%) of pneumonia and multiple organ failure and 1 of these had complications of postoperative deep unconsciousness and had bilateral intracranial carotid arterial stenosis. All of the surviving patients recovered uneventfully except for those in whom cerebral embolisms developed.
Conclusion: The described procedures were acceptable for high-risk patients with aortic thrombus and atheroma. We separately established cerebral circulation and systemic perfusion. The results suggest that these procedures could help avoid cerebral embolism by preventing atheromatous emboli from migrating to the brain. However, an alternative procedure should be devised for patients with intracranial arterial stenosis. The present results may have practical implications for the continuing evolution of treatment for such severe cases.

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