Heterogeneity of Surgical Strategies in Aortic Arch Surgery in European Aortic Centers

Background: To date, no clear standard of care has been established regarding cannulation strategies and organ protection measures in aortic arch surgery for aneurysms across European aortic centers. Therefore, we aimed to investigate the prevalence of various surgical strategies in aortic arch surgery at European centers.

Methods: To gain an overview of the various strategies for cannulation and organ protection in aortic arch surgery, we conducted an anonymous online survey among European cardiac surgery centers in September 2024.

Results: In total, 18 European centers for cardiac surgery participated in our survey with an average of 5.6 surgeons performing aortic arch surgery per center. All centers offer frozen elephant trunk (FET) procedures, with a mean of 19.9 cases annually (range 5–60). Distal aortic anastomoses during FET procedures are most commonly performed in Ishimaru zone 2 (77.8%) and/or zone 3 (44.4%), whereas in conventional arch replacements, zone 3 is preferred (85.7%). Temperature management also varies: 66.7% of centers use high–moderate hypothermia (24.1–28°C) for total arch replacement/ET/FET, while 11.1% of centers operate in mild hypothermia (28.1–34°C), and 22.2% below 24°C. For ascending replacements with open distal anastomosis, mild and high–moderate hypothermia are equally used (44.4% each). Selective cerebral perfusion is standard for total arch replacement/ET/FET (100%) and used in 88.9% of centers for hemiarch and ascending replacements with open distal anastomosis. Most centers favor antegrade (77.8%), bilateral (83.3%) perfusion, with brain monitoring primarily via near-infrared spectroscopy (94.4%). Spinal cord perfusion monitoring is rare (22.2%). Cardioplegia is commonly administered antegrade (72.2%) and/or retrograde (55.6%). In 22.2% of centers, non-cardioplegic myocardial perfusion is utilized. Histidine-tryptophan-ketoglutarate (Custodiol) is the preferred solution (58.8%). Common arterial cannulation sites for open distal anastomosis in ascending aortic aneurysms include the right subclavian artery (66.7%) and ascending aorta (33.3%). In total arch replacement/ET/FET, the most commonly used sites are the right subclavian artery (61.1%), the ascending aorta (27.8%), and the aortic arch (22.2%).

Conclusion: This survey reveals the heterogeneity of surgical strategies used in aortic arch surgery across European centers, highlighting the need for randomized trials to compare the safety and efficacy of the most commonly employed techniques.

Publication History

Article published online:
11 February 2025