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.