Sameh M. Said, MD, Harold M. Burkhart, MD, Joseph A

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Ascending-to-Descending Aortic Bypass: A Simple Solution to a Complex Problem Sameh M. Said, MD, Harold M. Burkhart, MD, Joseph A. Dearani, MD, Heidi M. Connolly, MD, Hartzell V. Schaff, MD The Annals of Thoracic Surgery Volume 97, Issue 6, Pages 2041-2048 (June 2014) DOI: 10.1016/j.athoracsur.2014.02.030 Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Illustrations show our technique of ascending–descending posterior pericardial aortic bypass. (A) The heart is elevated out of the pericardial well and into the right hemithorax. (B) An adequate area of the distal descending thoracic aorta is chosen for the distal anastomosis, and a side-biting vascular clamp is applied. (C) The distal anastomosis is constructed using continuous 4-0 polypropylene suture. (D) Air is removed from the graft. (E) The graft can be routed to the right side along the free wall of the right atrium to complete the proximal anastomosis. (F) The proximal anastomosis is constructed in a similar fashion with a side-biting clamp applied on the most distal portion of the lateral aspect of the ascending aorta to facilitate potential future aortotomy. (Reprinted from [6]. By permission of Mayo Foundation for Medical Education and Research. All rights reserved.) The Annals of Thoracic Surgery 2014 97, 2041-2048DOI: (10.1016/j.athoracsur.2014.02.030) Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 The bypass graft can be positioned on the right side along the right atrial free wall either (A) anterior or (B) posterior to the inferior vena cava or (C) along the left side anterior to the pulmonary artery. (Reprinted from [6]. By permission of Mayo Foundation for Medical Education and Research. All rights reserved.) The Annals of Thoracic Surgery 2014 97, 2041-2048DOI: (10.1016/j.athoracsur.2014.02.030) Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Kaplan-Meier survival curve (black line) shows long-term survival of the patients in the current study. (Reprinted from [6]. By permission of Mayo Foundation for Medical Education and Research. All rights reserved.) The Annals of Thoracic Surgery 2014 97, 2041-2048DOI: (10.1016/j.athoracsur.2014.02.030) Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Upper extremity systolic blood pressure (SBP) improved significantly after the ascending–descending bypass (p < 0.001). This improvement was in the early postoperative period and continued during the follow-up (FU). The horizontal line in the middle of each box indicates the median, the diamond in the center shows the mean and its confidence interval, the top and bottom borders of the box mark the 75th and 25th percentiles, respectively, the whiskers mark the 90th and 10th percentiles, and the circles indicate outliers. (Reprinted from [6]. By permission of Mayo Foundation for Medical Education and Research. All rights reserved.) The Annals of Thoracic Surgery 2014 97, 2041-2048DOI: (10.1016/j.athoracsur.2014.02.030) Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Upper extremity diastolic blood pressure (DBP) improved significantly after the ascending-descending bypass (p < 0.001). This improvement was in the early postoperative period and continued during the follow-up (FU). The horizontal line in the middle of each box indicates the median, the diamond in the center shows the mean and its confidence interval, the top and bottom borders of the box mark the 75th and 25th percentiles, respectively, the whiskers mark the 90th and 10th percentiles, and the circle indicates an outlier. (Reprinted from [6]. By permission of Mayo Foundation for Medical Education and Research. All rights reserved.) The Annals of Thoracic Surgery 2014 97, 2041-2048DOI: (10.1016/j.athoracsur.2014.02.030) Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

Fig 6 The average number of antihypertensive medications decreased significantly during the early postoperative period after the ascending–descending bypass (p = 0.04); however, this difference did not persist during the long-term follow-up (FU; p = 0.06) which may reflect the older age of our patient population at the time of reoperation. (Reprinted from [6]. By permission of Mayo Foundation for Medical Education and Research. All rights reserved.) The Annals of Thoracic Surgery 2014 97, 2041-2048DOI: (10.1016/j.athoracsur.2014.02.030) Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions