Single-stage extensive replacement of the thoracic aorta: The arch-first technique

Background: Single-stage extensive replacement of the thoracic aorta usuall y involves a period of circulatory arrest with performance of the graft-to- lower descending thoracic aorta anastomosis before performing the anastomos is to the arch vessels. To minimize the period of brain ischemia and reduce the potential for neurologic injury, we developed an alternative technique . Methods: In 6 patients with extensive aneurysms involving the entire thor acic aorta, exposure was obtained via a bilateral thoracotomy in the anteri or fourth intercostal space with transverse sternotomy, A 10-mm graft was a nastomosed to the aortic graft, opposite the site of the planned anastomosi s to the arch vessels. During a single period of circulatory arrest (34-46 minutes), the aortic graft was attached to a cuff of aorta containing the a rch vessels. The graft was then clamped on either side, and the arch was pe rfused with cold blood for 20 to 36 minutes. After the distal aortic anasto mosis was completed, antegrade perfusion was established via the 10-mm graf t, The proximal aortic anastomosis was performed last, Results: No patient sustained a permanent neurologic deficit. All 6 patients were discharged fr om the hospital, Conclusions: The "arch-first" technique, combined with a b ilateral transverse thoracotomy, allows expeditious replacement of the thor acic aorta with an acceptable interval of hypothermic circulatory arrest an d minimizes the risk of retrograde atheroembolism by establishing antegrade perfusion.