Surgical technique
Anesthesia management and cerebral perfusion technique are described
elsewhere.(3) Briefly, patient’s monitoring includes cannulation of two
peripheral arteries (left and right radial, or left radial and a femoral
artery), placement of a cerebral, oxygen-saturation monitoring device
(INVOS 4100, Somanetics Corp, Troy, MI, USA), cerebral perfusion
pressure line and check of actual cerebral blood flow by means of
trans-cranial Doppler.
Proximal repair is usually performed during cooling. Myocardial
protection is obtained with selective intra-coronary infusion of
antegrade, crystalloid cardioplegia (Custodiol HTK, Essential
Pharmaceutics LLC, Durham, NC, USA). HCA is carried out at a core
temperature of 25°C.
Cerebral perfusion is obtained with a standard Kazui technique when a
common femoral artery is used as the site for arterial return. If the
selected site is the right axillary artery, the systemic perfusion is
lowered at 0.5 L/min immediately before brachio-cephalic trunk clamping,
temporary unilateral brain perfusion through the right axillary-carotid
system and HCA are established, and the arch opened. The left common
carotid artery is then cannulated through its lumen, bilateral brain
perfusion is started, and the left subclavian artery clamped. Cerebral
flow is then adjusted based on INVOS signal, infusion pressure and
intracranial blood flow measurement.
The arch is resected completely, preserving the origins of the
supra-aortic vessels.