Anesthetic Management for Aortic Arch Surgery

Perfusion Strategy and Cannulation

Moderate hypothermia (target 20 °C–28 °C) combined with circulatory arrest and ante‑grade cerebral perfusion is the recommended strategy for aortic arch reconstruction, providing adequate cerebral oxygenation during the arrest period. Evidence level: strong consensus. [1][2]
Ante‑grade arterial cannulation is preferred over retrograde cannulation; axillary cannulation is specifically recommended for systemic ante‑grade perfusion because it reduces the risk of cerebral embolisation and improves neurological outcomes. Evidence level: strong consensus. [1][2]

Bilateral near‑infrared spectroscopy (NIRS) monitoring is mandatory throughout deep hypothermic circulatory arrest to detect real‑time cerebral hypoperfusion and allow immediate adjustment of perfusion strategies. Evidence level: strong consensus. [1][2]
Transcranial Doppler ultrasound may be added as an adjunct to tailor cerebral perfusion individually and to identify embolic events. Evidence level: moderate. [1][2]

Continuous nasopharyngeal temperature measurement together with a central temperature site (rectal or urinary) is required to ensure adequate cooling before arrest and controlled re‑warming afterward. Evidence level: strong consensus. [1][2]

Sodium thiopental can be considered for cerebral protection during aortic arch surgery with deep hypothermic circulatory arrest; the supporting data are of moderate quality. [1][2]
Steroids may also be used for neuroprotection in this setting, but the evidence is low. [1][2]

An α‑stat acid‑base strategy should be employed during moderate‑to‑deep hypothermia because it is associated with better neurological and neurocognitive outcomes. Evidence level: strong consensus. [1][2]
Peri‑operative magnesium sulfate may be administered to prophylax postoperative arrhythmias, enhance cardiac protection, and reduce postoperative neurocognitive dysfunction. Evidence level: moderate. [1][2]
A glucose‑insulin‑potassium (GIK) regimen can be considered to help prevent low‑cardiac‑output syndrome. Evidence level: moderate. [1][2]

Positive inotropes and/or vasopressors constitute first‑line therapy for LCOS occurring during cardiac surgery. Evidence level: strong consensus. [1][2]
Levosimendan should be considered in patients with reduced left‑ventricular ejection fraction to lower the risk of LCOS. Evidence level: moderate. [1][2]

A cardiopulmonary bypass (CPB) circuit must be primed and ready for immediate use in any emergency situation. Evidence level: strong consensus. [1][2]
After separation from CPB, the circuit should remain functional and on standby until the patient’s chest is closed. Evidence level: strong consensus. [1][2]
Extracorporeal life support (ECLS) equipment must be available at all times for rapid deployment if required. Evidence level: strong consensus. [1][2]

Implementation of goal‑directed fluid therapy using a standardized algorithm that incorporates mean arterial pressure, cardiac index, mixed‑venous oxygen saturation, and urine output reduces postoperative complications. Evidence level: high (randomized trial). 3

Re‑infusion of the processed residual volume from the CPB circuit at the end of the procedure should be considered to minimise the need for allogeneic blood transfusion. Evidence level: strong consensus. [1][2]