Surgical technique
Surgery was performed via median sternotomy or left lateral thoracotomy. The selection of one of the arterial accesses for cardiopulmonary bypass (CPB) (ascending aorta vs aortic arch vs brachiocephalic trunk vs right or left common carotid artery vs femoral artery) depended on the extent of aneurysm and/or dissection, the planned extent of the repair, as well as the cerebral protection method, and was left to the discretion of the operating surgeon. The right atrium was used for blood drainage for CPB. Depending on the central nervous system protection technique implemented during circulatory arrest, the patient was cooled to 17 degrees C (deep hypothermic circulatory arrest, DHCA) or 26 degrees C when selective brain perfusion was used. The patients’ body temperature was measured simultaneously in the esophagus and in the bladder. One of the 3 types of cardioplegic regimens was used: cold del Nido cardioplegic solution, cold blood cardioplegic solution (4:1 ratio) and cold miniplegia.
One of the following techniques was used for central nervous system protection:
The patients’ arterial blood pressure was monitored in both left and right radial arteries and in one of the femoral arteries.
The scope of aortic arch surgeries (open arch surgery):
Distal anastomosis with the descending aorta was performed end-to-end or in case of the co-existing descending aorta aneurysm with the use of the elephant trunk (ET) [9] or frozen elephant trunk (FET) technique [10]. The E-vita OPEN PLUS (Jotec Inc., Hechingen, Germany) system was used for the frozen elephant trunk procedures (Figure 1C).
The additional procedures performed on the aorta included:
supracoronary ascending aorta replacement for ascending aorta aneurysm,
aortic root replacement with coronary arteries re-implantation (Bentall de Bono technique) or valve sparing aortic root replacement (David method or Yacoub method) [11] for aortic root aneurysm.
Other concomitant procedures performed included: aortic valve replacement/aortic valve repair [12], mitral valve replacement/mitral valve repair, tricuspid valve repair, coronary artery bypass grafting.