The Strategy And Early Outcome Of Total Aortic Arch Replacement And The Frozen Elephant Trunk Technique With Aortic Balloon Occlusion

Objective:Total aortic arch replacement(TAR)with the frozen elephant trunk(FET)technique is the standard surgical technique used for treating complex aortic diseases in many aortic and vascular surgery centers.This surgical procedure is associated with more risks as the lower body undergoes long circulatory arrest(CA)with moderate to deep hyperthermia.For the first time,we discovered the novel bail-out usage of the Cook aortic balloon deployed by Gore sheath to perform aortic balloon occlusion technique in TAR with FET surgery.The current study will provide a report of the early outcomes for this procedure.Methods:All consecutive patients underwent TAR with FET operation(130 with aortic balloon occlusion,230 with conventional)in Fuwai Hospital were retrospectively reviewed in this study.The clinical end points and the related blood examination supporting them were recorded.The 1:1 propensity score matching and binary logistic regression were performed to establish both univariate and multivariate analysis on the effect of aortic balloon occlusion technique.Results:With the aortic balloon occlusion approach,the duration of lower body C A were significantly shortened from 17(14-20)min to 5(3-7)min(P<0.001)and CA nasal temperature rose from 25.40(24.90-26.00)? to 27.60(27.05-28.00)?.The 30-day mortality rate was 4.62%and 7.83%in aortic balloon occlusion group and conventional TAR with FET group with no statistical difference(P=0.241).The application of aortic balloon occlusion technique significantly reduced the incidence of postoperative acute kidney injury,hepatic injury,low cardiac output syndrome,severe lung infection,and prolonged mechanical ventilation(>72 h).It also shortened the time of conscious revival from anesthesia,and reduced red blood cell transfusion,but had limited effect of plasma and platelet transfusion.When the high risk subgroup cases was further investigated in this study,we found the application of aortic balloon occlusion technique was protective in the renal function of patients with preoperative Scr above normal,in-hospital survival of patients underwent cardiopulmonary bypass>210 min,and the renal function of patients aged less than but not more than 65 years.We also depicted the trajectory of blood routine test in both groups.The hemoglobin levels were similarly low in both groups and the neutrophil/lymphocyte ratio was much higher in conventional TAR with FET group.Both groups had drastic increase in platelet count before discharge due to the persistent platelet activation and aggregation in the earlier postoperative days.The alanine transaminase(ALT)progressively increased during in-hospital stay.The aspartate transaminase(AST)had a sharp rose during ICU stay and gradually recovered to normal range after transferred back to the ward.The pattern of the trajectory of ALT and AST reflected that they had different roles in indicating hepatic injury.The postoperative spike of AST suggested it being more sensitive to hepatic ischemic injury while the slow and steady elevation of ALT suggested it being more sensitive in reflecting the hepatic injury from drug metabolisms.Conclusions:The strategy of TAR and FET with aortic balloon occlusion has improved the early outcomes in reducing renal injury,hepatic injury and blood product transfusion by relieving the operative ischemic states.These specific improvements can provide crucial benefits to some subsets of patients when the aortic balloon occlusion technique was used properly.With the encouraging results we have so far,this technique deserves further recognition in the future clinical practice.