Use of carotid–subclavian arterial bypass and thoracic endovascular aortic repair to minimize cerebral ischemia in total aortic arch reconstruction Steve.

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Use of carotid–subclavian arterial bypass and thoracic endovascular aortic repair to minimize cerebral ischemia in total aortic arch reconstruction Steve Xydas, MD, Benjamin Wei, MD, Hiroo Takayama, MD, Mark Russo, MD, Matthew Bacchetta, MD, Craig R. Smith, MD, Allan Stewart, MD The Journal of Thoracic and Cardiovascular Surgery Volume 139, Issue 3, Pages 717-722 (March 2010) DOI: 10.1016/j.jtcvs.2009.10.040 Copyright © 2010 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 Photograph depicting example of custom-made Dacron polyester fabric graft (Terumo Cardiovascular Systems, Ann Arbor, Mich) currently being used for hybrid total arch reconstruction. Labels denote graft orientations of proximal and distal ends, as well as side arms for the innominate and left carotid anastomoses. There is additional 9-mm side arm for access with concomitant thoracic endovascular aneurysm repair. This is performed in an antegrade fashion into the distal end of the graft to complete the total arch reconstruction. If staged thoracic endovascular aneurysm repair is performed endovascularly, radiopaque markers aid in this transfemoral approach, marking the most proximal margin of proximal landing zone. The Journal of Thoracic and Cardiovascular Surgery 2010 139, 717-722DOI: (10.1016/j.jtcvs.2009.10.040) Copyright © 2010 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 Illustration depicting completed open repair in the group II patients. Approach involves starting with left carotid subclavian bypass. Graft–left carotid anastomosis is performed off cardiopulmonary bypass after clamping of left carotid artery. During this time, blood supply is temporarily provided through left subclavian–left carotid flow. Subsequently, selective antegrade cerebral perfusion is instituted for graft–innominate artery and distal aortic anastomoses. Proximal graft is then clamped, and full cardiopulmonary flow reinstituted. Proximal anastomosis is completed during rewarming. Left subclavian artery is typically ligated at end of procedure through sternotomy to avoid competitive flow with left carotid–subclavian arterial bypass. Thoracic endograft is used to complete arch replacement, with distal aortic graft as proximal landing zone. The Journal of Thoracic and Cardiovascular Surgery 2010 139, 717-722DOI: (10.1016/j.jtcvs.2009.10.040) Copyright © 2010 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 Group II had significantly shorter selective antegrade cerebral perfusion (SACP), cardiopulmonary bypass (CPB), and aortic crossclamp times than did group I. The Journal of Thoracic and Cardiovascular Surgery 2010 139, 717-722DOI: (10.1016/j.jtcvs.2009.10.040) Copyright © 2010 The American Association for Thoracic Surgery Terms and Conditions