1. Prosthesis for Aortic Arch Substitution
Stefano Nazari, MD, Susanna Salvi, MD, Alessandro Aluffi, MD, Ettore Visconti, MD, Giuseppe Rescigno, MD, Paolo Buniva, MD 
The Annals of Thoracic Surgery 
Volume 64, Issue 5, Pages (November 1997)
DOI: /S (97)
Copyright © 1997 The Society of Thoracic Surgeons Terms and Conditions

2. Fig 1
The working principle of the device relies on a number of metallic wires, sewn to a Dacron prosthesis, arranged in several circular loops. Traction on the wires by an actuating guide allows the loops to be expanded and tightened in such a way that the diameter of the prosthesis varies, while maintaining a regular cylindric shape. The prosthesis end then becomes a rigid cylindrical ring with a variable and controllable diameter. (Reproduced with permission from Nazari S, Luzzana F, Banfi C, et al. Expandable prosthesis for sutureless anastomosis in thoracic aorta prosthetic substitution. Eur J Cardiothorac Surg 1996;10:1003–9. © 1996 Springer-Verlag GmbH & Co.)
The Annals of Thoracic Surgery  , DOI: ( /S (97) )
Copyright © 1997 The Society of Thoracic Surgeons Terms and Conditions

3. Fig 2
The device is realized in different sizes and is fitted with a flexible guide with its actuating handle (top left). The prosthesis segment required for substitution is cut to the appropriate length and sutured inside the expandable segment before cross-clamping (top right, bottom left). The metallic wires of the expandable prosthesis end constitute a rigid ring, approximately half its maximal diameter in length. When blood flow is reestablished, the guide is cut as close as possible to the expandable end and removed. The device allows the prosthesis end diameter to be reduced up to 20% to 40% of its maximal diameter (bottom left). The optimal opening of the device when in the site is within 70% and 90% of its maximal aperture. (Reproduced with permission from Nazari S, Luzzana F, Banfi C, et al. Expandable prosthesis for sutureless anastomosis in thoracic aorta prosthetic substitution. Eur J Cardiothorac Surg 1996;10:1003–9. © 1996 Springer-Verlag GmbH & Co.)
The Annals of Thoracic Surgery  , DOI: ( /S (97) )
Copyright © 1997 The Society of Thoracic Surgeons Terms and Conditions

4. Fig 3
For arch substitution a composite graft can be prepared, fitted with the expandable device at the distal end of the main prosthesis as well as at each end of the branches for the supraortic trunks. The retracted expandable ends are positioned into the corresponding branches and then opened, during a brief hypothermic circulatory arrest; ascending aortic anastomosis can be carried out with the standard technique (or with the quick anastomotic ring shown in Figure 6) during the rewarming phase, while the central nervous system perfusion is resumed.
The Annals of Thoracic Surgery  , DOI: ( /S (97) )
Copyright © 1997 The Society of Thoracic Surgeons Terms and Conditions

5. Fig 4
(A) The device used in this experimental series includes only two supraaortic branches, due to the particular arch conformation of the swine strain used. (B) The anterior appearance of the arch with the device at sacrifice. (C) The prosthesis and arch viewed from the upper side.
The Annals of Thoracic Surgery  , DOI: ( /S (97) )
Copyright © 1997 The Society of Thoracic Surgeons Terms and Conditions

6. Fig 5
With the intraluminal ringed prosthesis a diameter rather smaller than that appearing appropriate must be used to keep the clamping time shorter than that achievable with a standard suture. The aorta in fact significantly reduces its diameter when clamped; moreover, due to the floppy consistency of the aortic wall, a significant gap must be left between the external diameter of the intraluminal ring and the internal aortic wall to allow introduction without friction. The expandable prosthesis overcomes all these adverse conditions. (Reproduced with permission from Nazari S, Luzzana F, Banfi C, et al. Expandable prosthesis for sutureless anastomosis in thoracic aorta prosthetic substitution. Eur J Cardiothorac Surg 1996; 10:1003–9. © 1996 Springer-Verlag GmbH & Co.)
The Annals of Thoracic Surgery  , DOI: ( /S (97) )
Copyright © 1997 The Society of Thoracic Surgeons Terms and Conditions

7. Fig 6
Other possible uses of the expandable prosthesis may include aneurysms of descending thoracic aorta: (A) A modified version of the device (quick anastomotic ring) in which both ends of a short prosthetic segment are actuated simultaneously by only one guide [5] may be used in the repair of traumatic isthmic rupture (B), or for end-to-end prosthesis or vascular anastomosis (co-arctation).
The Annals of Thoracic Surgery  , DOI: ( /S (97) )
Copyright © 1997 The Society of Thoracic Surgeons Terms and Conditions

8. Fig 7
When a clamp is applied, it is important to keep the length of the vascular stump significantly longer than usual to allow full expansion of the expandable end.
The Annals of Thoracic Surgery  , DOI: ( /S (97) )
Copyright © 1997 The Society of Thoracic Surgeons Terms and Conditions

9. Fig 8
The expandable end also can be positioned against aneurysmal wall, provided that its distal end would reach the healthy vascular wall. Thrombosis of the tract between the ligature and the prosthesis end will soon move the effective anastomosis line (*) where it would be with standard suture.
The Annals of Thoracic Surgery  , DOI: ( /S (97) )
Copyright © 1997 The Society of Thoracic Surgeons Terms and Conditions