HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Marc A. A. M. Schepens Karl M. Dossche Teruhisa Kazui Roberto Di Bartolomeo Davide Pacini Angelo Pierangeli Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Di Eusanio, M. Articles by Pierangeli, A. Search for Related Content PubMed PubMed Citation Articles by Di Eusanio, M. Articles by Pierangeli, A. Related Collections Great vessels

Ann Thorac Surg 2004;77:2021-2028
© 2004 The Society of Thoracic Surgeons

---

Original article: cardiovascular

Separate grafts or en bloc anastomosis for arch vessels reimplantation to the aortic arch

^a Department of Cardiac Surgery, "GM Lancisi" Hospital, Ancona, Italy
^b Department of Cardiopulmonary Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
^c First Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
^d Department of Cardiac Surgery, Policlinico S Orsola, University of Bologna, Bologna, Italy

Accepted for publication October 28, 2003.

^* Address reprint requests to Dr Di Eusanio, Dipartimento di Cardiochirurgia, Ospedale "GM Lancisi," Via Conca 71, 60020, Torrette-Ancona, Italy.
e-mail: m_dieus{at}hotmail.com

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
BACKGROUND: This study compares the results of the separated graft technique and the en bloc technique as a method of arch vessels reimplantation during surgery of the aortic arch and determines the predictive risk factors associated with hospital mortality and adverse neurologic outcome during aortic arch repair.

METHODS: Between October 1995 and March 2002, 352 patients (mean age 64.9 ± 11.3 years; urgent status: 49/352 [13.9%]) underwent surgery of the aortic arch using the separated graft technique (group A: n = 230 [65.3%]) and the en bloc technique (group B: n = 122 [34.7%]) to reimplant the arch vessels. An aortic arch replacement was performed in 32 patients (9.1%), an ascending aorta and arch replacement in 222 patients (53.1%), an aortic arch and descending aorta replacement in 16 patients (4.5%), and a complete replacement of the thoracic aorta in 82 patients (23.3%). Brain protection was achieved by means of antegrade selective cerebral perfusion in all patients. The mean cardiopulmonary bypass time was 204.8 ± 61.9 minutes (group A: 199.7 ± 57.0 minutes; group B: 214.5 ± 69.4 minutes; p = 0.033), the mean myocardial ischemic time was 121.5 ± 43.2 minutes (group A: 116.7 ± 38.9 minutes; group B: 130.80 ± 49.4 minutes; p = 0.003), and the mean antegrade selective cerebral perfusion time was 84.5 ± 36.4 (group A: separated graft technique 91.3 ± 36.3 minutes; group B: 70.6 ± 32.7 minutes; p = 0.000).

RESULTS: Overall hospital mortality was 6.8% (group A: 6.5%; group B: 7.4%; p = not significant [NS]). The permanent neurologic dysfunction rate was 3.5% (group A: 4.0%; group B: 2.5%; p = NS). The transient neurologic dysfunction rate was 5.4% (group A: 5.5%; group B: 5.2%, p = NS). Postoperative systemic morbidity was similar in the two groups. A logistic regression analysis revealed preoperative cardiac tamponade (p = 0.011; odds ratio [OR] = 5.9) and cardiopulmonary bypass time (p = 0.010; OR = 1.01/min) to be independent predictors of hospital mortality. None of the analyzed preoperative variables were associated with an increased risk of permanent neurologic dysfunction. Age more than 70 years old (p = 0.029, OR = 5.7), myocardial revascularization (p = 0.001, OR = 2.9), and pump time (p = 0.013, OR = 1.01/min) were indicated as independent predictors of transient neurologic dysfunction by logistic regression.

CONCLUSIONS: Antegrade selective cerebral perfusion was confirmed to be a safe method of cerebral protection allowing complex aortic arch operations to be performed with acceptable results in terms of hospital mortality and neurologic outcome. The separated graft technique had no adverse impact on hospital mortality and morbidity.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
Protection of the brain from ischemic/embolic injuries and selection of adequate operative techniques are primary concerns during surgery of the aortic arch.

In our institutions, a progressive improvement of survival and neurologic outcome in patients undergoing complex aortic repairs has gone through the following steps:

1. Utilization of antegrade selective cerebral perfusion (ASCP) and moderate hypothermia as a method of brain protection for aortic operations requiring a circulatory arrest longer than 30 minutes.
   
2. Utilization of alternative cannulation sites, such as the ascending aorta and the right axillary artery, in combination with antegrade resumption of the cardiopulmonary bypass (CPB) to reduce cerebral embolic injuries.
   

The en bloc technique (EBT) and the separated graft technique (SGT) are currently being used as a method of arch vessels reimplantation during aortic arch reconstructions.

The objectives of the present study were to determine the independent predictive risk factors for hospital mortality and neurologic outcome in 352 patients undergoing aortic arch replacement with the aid of ASCP, and to compare (and comment on) the two different techniques for aortic arch vessels reimplantation during aortic arch operations.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
Between October 1995 and March 2002, 352 patients underwent surgery of the aortic arch at the St Antonius Hospital (Nieuwegein, The Netherlands), the Hamamatsu University (Hamamatsu, Japan), and at the Sant'Orsola Hospital (University of Bologna, Bologna, Italy). Table 1 provides the details for these centers. The arch vessels were reimplanted on the aortic arch using the separated graft technique (SGT group: n = 230 [65.3%]) or the en bloc technique (EBT group: n = 122 [34.7%]). Brain protection was achieved by means of ASCP in all patients.

Medical records were reviewed for clinical variables including preoperative status, intraoperative data, and early postoperative complications. There were 178 men (50.6%); the mean patient age was 64.9 ± 11.3 years (range 23 to 85 years old). The indications for surgery were acute type A dissection in 49 patients (13.9%) and chronic postdissection aneurysm or degenerative aneurysm in 303 (86.1%). Two hundred thirty-six patients (67.3%) presented with arterial hypertension, 50 patients (14.2%) had coronary artery disease, 40 patients (11.4%) had history of cerebrovascular disease (previous stroke or transient ischemic attack), 47 patients (13.4%) had chronic obstructive pulmonary disease (FEV₁ = 50 to 70%, medical therapy), and 20 patients (5.7%) had chronic renal insufficiency (creatinine > 120 µmol/L). Out of 49 patients with type A aortic dissection, 12 patients (24.4%) presented with cardiac tamponade and 8 patients (16.3%) with acute aortic insufficiency.

Sixty patients (17%) had undergone a previous cardiovascular operation using a median sternotomy. Patient demographics were essentially similar in the two groups. The SGT group had more coronary disease and more history of cerebrovascular disease compared with the EBT group (Table 2).

Operative technique
Induction of anesthesia was obtained with propofol 2 mg/kg, fentanyl 2 µg/kg, and pancuronium 0.1 mg/kg. Anesthesia was maintained with propofol and fentanyl. For all patients, pH balance control was carried out using the -stat method. No pharmacologic neuroprotective agents were administered. Our platform for cerebral monitoring has previously been described [1, 2] and included a right radial arterial pressure line in all patients, electroencephalogram, regional oxygen saturation in the bilateral frontal lobes by means of a near-infrared spectroscopy, jugular venous oxygen saturation, and TCD measurement of the blood velocity of the middle cerebral artery when available. Transesophageal echocardiography was routinely used.

To approach the thoracic aorta, a median sternotomy was used in 347 patients (98.6%) and a median sternotomy plus left anterolateral thoracotomy in 5 patients (1.4%). After systemic heparinization, CPB was instituted with a cannula for arterial return in the femoral artery, ascending aorta or right axillary artery, and with a venous single two-stage cannula in the right atrium for venous drainage. The left side of the heart was vented through the right superior pulmonary vein. Myocardial protection was achieved with cold crystalloid or blood cardioplegia.

Details of our cannulation technique and method of ASCP with moderate hypothermic circulatory arrest have previously been described [3–5]. Briefly, after the cardiopulmonary bypass was instituted and the patients were cooled to a nasopharyngeal temperature of 22 to 26°C, the systemic circulation was arrested and the aorta opened. With the patient in the Trendelenburg position, special catheters for ASCP (Fuji System Corporation, Tokyo, Japan) [6] or 15 F ordinary retrograde coronary sinus perfusion cannulas (Medtronic DLP; Chase Medical Inc, Houston, TX), connected to the oxygenator with a separate single-roller pump head, were inserted into the innominate and left common carotid arteries through the opened aorta. The left subclavian artery was clamped or occluded with a Fogarty catheter (Baxter Health Care, Irvine CA) in order to avoid the steal phenomenon.

Cerebral perfusion was initiated at a rate of 10 mL · kg^–1 · min^–1 and adjusted to maintain a right radial arterial pressure of between 40 and 70 mm Hg. During open distal anastomosis, blood perfusion to the lower half was usually arrested. If the EBT was used for arch vessels reimplantation, an aortic cuff containing the orifices of the arch vessels was prepared and anastomosed in an end-to-side fashion to the side hole of the aortic graft [7]. Following the reconstruction of the arch vessels, the ASCP catheters were removed, and after careful deairing, the aortic graft was cross-clamped and CPB was restarted in an antegrade fashion through a side branch of the aortic graft or through the axillary artery. Rewarming was initiated. The proximal end of the graft was then anastomosed to the proximal stump of the ascending aorta.

Our technique of aortic arch replacement with a four-branched aortic graft (SGT) has already been described in detail [8]. After circulatory arrest was established, with the patient in the Trendelenburg position, the aorta was opened and the arch vessels completely transected 1.5 to 2 cm from the junction with the aortic arch. The ASCP catheters were inserted into the innominate artery and the left common carotid artery while the left subclavian artery was occluded. ASCP was started. The distal side of the arch graft was anastomosed to the proximal descending aorta, and the third branch was anastomosed to the left subclavian artery. The graft was cross-clamped proximally, and antegrade extracorporeal circulation was restarted from the fourth branch, togheter with rewarming. The proximal graft was anstomosed to the ascending aorta and coronary circulation was started. The first and second branches of the graft were then anastomosed to the innominate and left common carotid artery, respectively. Once CPB was discontinued, the fourth branch, used for antegrade perfusion, was oversewn and resected.

In order to further reduce the duration of spinal cord ischemia we have recently modified our technique. The distal side of the arch graft was anastomosed to the proximal descending aorta under systemic circulatory arrest, the graft was cross-clamped proximally, and then antegrade systemic perfusion was started from the fourth branch of the graft. Then, the left subclavian artery was sutured to the third branch of the graft, and rewarming was started. The proximal graft was anastomosed to the ascending aorta and coronary circulation was started. The first and second branches of the graft were then anastomosed to the innominate and left common carotid artery, respectively. Once CPB was discontinued, the fourth branch, used for antegrade perfusion, was oversewn and resected.

The extent of the aortic replacement and the associated procedures are listed in Table 3, and the operative data in Table 4. Although there were neither differences in aortic pathology nor differences in the technical threshold between the two groups, the Bentall procedure was incidentally preferred in patients receiving the en bloc technique by some surgeons (p = 0.007).

The analysis for PND (stroke or coma) and TND (postoperative confusion, agitation, delirium, prolonged obtundation or transient parkinsonism with negative brain computed tomographic scanning and complete resolution before discharge) were conducted separately. Risk factors for PND were examined in all patients who survived the operation long enough to undergo neurologic evaluation. Risk factors for TND were assessed in all operative survivors without PND. Statistical analysis was performed using SPSS 10.0 statistical software (SPSS Inc, Chicago, IL).

	Results

Top Abstract Introduction Material and methods Results Comment References

 
Hospital mortality
Twenty-four patients died during hospitalization, for an overall in-hospital mortality rate of 6.8%. The hospital mortality was 16/303 (5.3%) for elective surgery and 8/49 (16.3%) for urgent surgery (p = 0.010). Causes of death were: multiorgan failure (n = 11), septic shock (n = 2), neurologic damage (n = 2), low cardiac output (n = 3), bleeding (n = 3), and rupture of a distal aneurysm (n = 3).

On univariate analysis, the following factors had a significant influence on hospital mortality: urgent status (p = 0.010), acute dissection complicated by tamponade (p = 0.006), preoperative renal insufficiency (p = 0.039), and prolonged CPB time (240.1 ± 83.9 vs 202.2 ± 59.2; p = 0.004). Multivariate analysis revealed type A aortic dissection complicated by tamponade (p = 0.011; odds ratio [OR] = 5.9) and CPB time (p = 0.010; OR = 1.01/min) to be independent predictors of hospital mortality (Table 5).

Transient neurologic dysfunction, which was evaluated only in patients without permanent neurologic damage, occurred in 18 of 333 patients (5.4%).

Age more than 70 years (p = 0.022), coronary artery disease (p = 0.025), aortic valve replacement (p = 0.017), coronary artery bypass grafting (p = 0.016), and CPB time (233.7 ± 58.5 vs 200.2 ± 57.3; p = 0.019) were associated with a significantly increased risk of TND on univariate analysis. Stepwise logistic regression indicated age more than 70 years old (p = 0.029, OR = 5.7), CPB time (p = 0.013, OR = 1.01/min), and coronary artery bypass grafting (p = 0.001, OR = 2.9) as independent predictors of TND (Table 6). ASCP time was not associated with increased hospital mortality and adverse neurologic outcome.

No differences in terms of hospital mortality, neurologic outcome, or other postoperative complications were observed between the SGT group and the EBT group (Table 7).

	Comment

Top Abstract Introduction Material and methods Results Comment References

1. We have demonstrated that an ASCP time longer than 90 minutes and the extent of the aortic replacement are not associated with an increased risk of hospital mortality and adverse neurologic outcome [9]. In this series the prolonged ASCP time obserevd in the SGT group did not result in an increased hospital mortality and adverse nerologic rates.
   
2. ASCP is associated with a lower incidence of TND in patients undergoing aortic arch reconstruction of 40 to 80 minutes as compared to deep hypothermic circulatory arrest (DHCA) with or without retrograde cerebral perfusion (RCP) [10].
   
3. ASCP may be used with moderate hypothermia instead of deep hypothermia. Our previous experimental study indicated that under moderate hypothermia (22 to 25°C), 10 mL · kg^–1 · min^–1 was an adequate cerebral perfusion volume to support an aerobic cerebral metabolism [11]. Thus, we don't believe that the same perfusion volume at more profound hypothermia would reduce the incidence of the neurologic dysfunction, but rather would only result in a higher incidence of pulmonary, renal, endothelial, microembolic complications related to both the need of prolonged periods of CPB and profound hypothermia [9].
   
4. ASCP is more effective in supplying oxygenated blood to the brain resulting in a more physiologic brain energy metabolism and cerebral function preservation as compared to DHCA with or without RCP [12–15].
   

We tried to reduce our stroke rate by avoiding, when possible, a retrograde arterial perfusion from the femoral artery and preferring alternative cannulation sites such as the ascending aorta or the right axillary artery [16–18]. Restarting the CPB in and antegrade fashion through the side branch of the aortic graft or through the axillary artery may also reduce the embolic load to the brain, and during dissection repairs, prevent both organ malperfusion and excessive stress on the distal sutureline.

Different techniques for aortic arch reconstruction have been described [7, 8, 10]. In our institutions, EBT and SGT are currently being used as techniques for arch vessel reimplantation during aortic arch reconstruction.

SGT presents several advantages

1. The cerebral embolic risk may be reduced by replacing the aortic arch and proximal portion of the arch vessels where clots, atheroma, and calcification are very often located. We do not believe that the insertion of the catheters results in a significantly increased risk of embolization. In fact, aortic manipulation is carefully avoided until circulatory arrest is established. The arch vessels are transected 1.5 to 2.0 cm distally from the junction with the aortic arch where the likelihood of dislodging debris is low, the arch vessel cannulation is performed under direct visualization, and the balloons at the tip of the catheters are not traumatic and even more distally placed. In our series, the SGT group had a higher predicted risk of postoperative PND as compared to the EBT group, the incidence of preoperative old brain infarction being higher [19] and the atherosclerotic involvement of the aorta more severe [20]. Despite that, the SGT group stroke rate compared favorably with the EBT group stroke rate (SGT group 4.0%; EBT group 2.5%; p = NS), and with that reported by others [10, 21, 22].
   
2. CPB time and myocardial ischemic time are shorter than those necessary in EBT. It is well-known that pump time is one of the most important risk factor for hospital mortality. In our series, a prolonged CPB time was associated with an increased risk of hospital mortality, TND, bleeding, and pulmonary/renal dysfunction after surgery. However, using the SGT did not result in better hospital survival nor in a lower morbidity.
   
3. Lower body ischemia can be substantially reduced.
   
4. Utilization of a four-branched aortic graft can maximally reduce ischemia in the left subclavian artery region [8].
   
5. Pathologic portions of the aortic arch can be completely resected in Marfan patients.
   
6. Anastomosis can be performed at the intact distal site of the arch vessels where dissection has not extended.
   
7. Bleeding at the site of the arch vessel anastomosis can be easily controlled.
   

Hagl and coworkers [10], Spielvogel and colleagues [23], and Rokkas and associates [24] have described different techniques for aortic arch replacement: first, the arch vessels are anastomosed to a main aortic graft as separate grafts or in an island fashion under a period of DHCA. After establishing ASCP through the graft (or axillary artery), the distal and proximal aortic anastomoses are accomplished. These techniques require a period of DHCA of about 30 minutes for the arch vessels reconstruction, prolonged periods of spinal cord ischemia, and probably result in a more technically demanding distal anastomosis because the aortic graft makes the operative field cluttered. With SGT, since safe brain protection is guaranteed by ASCP and moderate hypothermia, distal anastomosis becomes the most important part of the procedure. Thus, we perform it as first, with open technique. Moreover, with SGT, the duration of the total circulatory arrest required to open the aorta, transect and cannulate the arch vessels with our bolloon catheters is reduced to about 3 minutes, and spinal cord ischemia is maximally reduced.

In this series involving 352 patients undergoing aortic arch replacement with ASCP for brain protection and SGT and EBT for arch vessels reimplantation, the hospital mortality rate was 6.8%; PND and TND rates were 3.5% and 5.4%, respectively. Given the pathologic background of the patients, the complexity of the reconstructions and the high rate of associated procedures, these results can be considered satisfactory. Confirming our previous reports, type A aortic dissection complicated by tamponade and CPB time were indicated as independent predictive risk factors for hospital mortality. CPB time, CABG, and age more than 70 years old were associated with an increased risk of TND [3, 9, 25, 26]. This finding confirmed that the duration of ASCP and the extent of aortic replacement does not impact the patients' outcome and that the CPB time remains the most important intraoperative factor to influence results during complex aortic repairs. Even though SGT did not result in an improved survival nor in a better neurologic outcome as compared to EBT, it provided numerous technical advantages and required shorter periods of CPB and cardiac ischemia.

	References

Top Abstract Introduction Material and methods Results Comment References

 

1. Di Eusanio M., Tan M.E.S.H., Schepens M.A., Dossche K.M., Di Bartolomeo R., Pierangeli A., Morshuis W.J. Surgery for acute type A dissection using antegrade selective cerebral perfusion: experience in one-hundred-twenty-two patients. AnnThorac Surg 2003;75:514-519.[Abstract/Free Full Text]
2. Kazui T., Washiyama N., Muhammad B.A., Terada H., Yamashita K., Takinami M. Improved results of atherosclerotic arch aneurysm operations with a refined technique. J Thorac Cardiovasc Surg 2001;121:491-499.[Abstract/Free Full Text]
3. Di Bartolomeo R., Di Eusanio M., Pacini D., et al. Antegrade selective cerebral perfusion during surgery of the thoracic aorta: risk analysis. Eur J Cardiothorac Surg 2001;19:765-770.[Abstract/Free Full Text]
4. Dossche K.M., Schepens M.A., Morshuis W.J., Muysoms F.E., Langemeijer J.J., Vermeulen F.E. Antegrade selective cerebral perfusion in operations on the proximal thoracic aorta. Ann Thorac Surg 1999;67:1904-1910.[Abstract/Free Full Text]
5. Kazui T., Kimura N., Yamada O., Komatsu S. Surgical outcome of aortic arch aneurysms using selective cerebral perfusion. Ann Thorac Surg 1994;57:904-911.[Abstract]
6. Kazui T. Simple and safe cannulation technique for antegrade selective cerebral perfusion. Ann Thorac Cardiovasc Surg 2001;7:186-188.[Medline]
7. Pearce C, Weichert R, del Real R. Aneurysms of aortic arch. Simplified technique for excision and prosthetic replacement. J Thorac Cardiovasc Surg 1969:886–90
8. Kazui T., Washiyama N., Muhammad B.A., et al. Total arch replacement using aortic arch branched grafts with the aid of antegrade selective cerebral perfusion. Ann Thorac Surg 2000;70:3-8.[Abstract/Free Full Text]
9. Di Eusanio M., Schepens M.A., Morshuis W.J., Di Bartolomeo R., Pierangeli A., Dossche K.M. Antegrade selective cerebral perfusion during operations on the thoracic aorta: factors influencing survival and neurologic outcome in 413 patients. J Thorac Cardiovasc Surg 2002;124:1080-1086.[Abstract/Free Full Text]
10. Hagl C., Ergin M.A., Galla J.D., et al. Neurologic outcome after ascending aorta-aortic arch operations: effect of brain protection technique in high-risk patients. J Thorac Cardiovasc Surg 2001;121:1107-1121.[Abstract/Free Full Text]
11. Tanaka H., Kazui T., Sato H., Inoue N., Yamada O., Komatsu S. Experimental study on the optimum flow rate and pressure for selective cerebral perfusion. Ann Thorac Surg 1995;59:651-657.[Abstract/Free Full Text]
12. Sakurada T., Kazui T., Tanaka H., Komatsu S. Comparative experimental study of cerebral protection during aortic arch reconstruction. Ann Thorac Surg 1996;61:1348-1354.[Abstract/Free Full Text]
13. Filgueiras C.L., Winsborrow B., Ye J., et al. A 31p-magnetic resonance study of antegrade, and retrograde cerebral perfusion during aortic arch surgery in pigs. J Thorac Cardiovasc Surg 1995;110:55-62.[Abstract/Free Full Text]
14. Juvonen T., Weisz D.J., Wolfe D., et al. Can retrograde perfusion mitigate cerebral injury after particulate embolization? A study in a chronic porcine model. J Thorac Cardiovasc Surg 1998;115:1142-1159.[Abstract/Free Full Text]
15. Midulla P.S., Gandsas A., Sadeghi A.M., et al. Comparison of retrograde cerebral perfusion to antegrade cerebral perfusion and hypothermic circulatory arrest in a chronic porcine model. J Card Surg 1994;9:560-574.[Medline]
16. Sabik J.F., Lytle B.W., McCarthy P.M., Cosgrove D.M. Axillary artery: an alternative site of arterial cannulation for patients with extensive aortic and and peripheral vascular disease. J Thorac Cardiovasc Surg 1995;109:885-890.[Abstract]
17. Westaby S., Katsumata T. Proximal aortic perfusion for complex arch and descending aortic disease. J Thorac Cardiovasc Surg 1998;115:162-167.[Abstract/Free Full Text]
18. Mazzola A., Gregorini R., Villani C., Di Eusanio M. Antegrade cerebral perfusion by axillary artery and left carotid artery inflow at moderate hypothermia. Eur J Cardiothorac Surg 2002;21:930-931.[Abstract/Free Full Text]
19. Washiyama N., Kazui T., Takinami M., et al. Experimental study on the effect of antegrade cerebral perfusion on brains with old cerebral infarction. J Thorac Cardiovasc Surg 2001;122:734-740.[Abstract/Free Full Text]
20. Ergin M.A., Galla J.D., Lansman S., Quintana C., Bodian C., Griepp R.B. Hypothermic circulatory arrest in operations on the thoracic aorta. Determinants of operative mortality and neurologic outcome. J Thorac Cardiovasc Surg 1994;107:788-797.[Abstract/Free Full Text]
21. Ueda Y., Miki S., Kusuhara K., Okita Y., Tahata T., Yamanaka K. Surgical treatment of aneurysm or dissection involving the ascending aorta and aortic arch, utilizing circulatory arrest and retrograde cerebral perfusion. J Cardiovasc Surg (Torino) 1990;31:553-558.[Medline]
22. Bachet J., Guilmet D., Goudot B., et al. Cold cerebroplegia. A new technique of cerebral protection during operations on the transverse aortic arch. J Thorac Cardiovasc Surg 1991;102:85-93.[Abstract]
23. Spielvogel D, Strauch JT, Minanov OP, Lansman SL, Griepp RB. Aortic arch replacement using a trifurcated graft and selective cerebral antegrade perfusion. Ann Thorac Surg 2002;S1810–4
24. Rokkas C.K., Kouchoukos N.T. Single-stage extensive replacement of the thoracic aorta: the arch- first technique. J Thorac Cardiovasc Surg 1999;117:99-105.[Abstract/Free Full Text]
25. Kazui T., Yamashita K., Washiyama N., et al. Usefulness of antegrade selective cerebral perfusion during aortic arch operations. Ann Thorac Surg 2002;74:S1806-1809.[Abstract/Free Full Text]
26. Dossche K.M., Morshuis W.J., Schepens M.A., Waanders F.G. Bilateral antegrade selective cerebral perfusion during surgery on the proximal thoracic aorta. Eur J Cardiothorac Surg 2000;17:462-467.[Abstract/Free Full Text]

This article has been cited by other articles:

				M. Gorlitzer, G. Weiss, M. Thalmann, G. Mertikian, W. Wislocki, J. Meinhart, F. Waldenberger, and M. Grabenwoger Combined Surgical and Endovascular Repair of Complex Aortic Pathologies With a New Hybrid Prosthesis Ann. Thorac. Surg., December 1, 2007; 84(6): 1971 - 1976. [Abstract] [Full Text] [PDF]

				M. Czerny, R. Gottardi, D. Zimpfer, M. Schoder, M. Grabenwoger, J. Lammer, E. Wolner, and M. Grimm Mid-term results of supraaortic transpositions for extended endovascular repair of aortic arch pathologies Eur. J. Cardiothorac. Surg., April 1, 2007; 31(4): 623 - 627. [Abstract] [Full Text] [PDF]

				D. Spielvogel, C. D. Etz, D. Silovitz, S. L. Lansman, and R. B. Griepp Aortic Arch Replacement With a Trifurcated Graft Ann. Thorac. Surg., February 1, 2007; 83(2): S791 - S795. [Abstract] [Full Text] [PDF]

				T. Kazui Total arch replacement: technique of separate reimplantation of epi-aortic vessels MMCTS, January 2, 2007; 2007(0102): 1925. [Abstract] [Full Text] [PDF]

				K. Suzuki, T. Kazui, A. H. M. Bashar, K. Yamashita, H. Terada, N. Washiyama, and T. Suzuki Total Aortic Arch Replacement in Patients With Arch Vessel Anomalies Ann. Thorac. Surg., June 1, 2006; 81(6): 2079 - 2083. [Abstract] [Full Text] [PDF]

				F. Jault, A. Rama, L. Lievre, N. Bonnet, P. Leprince, A. Pavie, and I. Gandjbakhch Chronic dissection of the ascending aorta: surgical results during a 20-year period (previous surgery excluded). Eur. J. Cardiothorac. Surg., June 1, 2006; 29(6): 1041 - 1045. [Abstract] [Full Text] [PDF]

				A. Della Corte, M. Scardone, G. Romano, C. Amarelli, A. Biondi, L. S. De Santo, M. De Feo, G. Nappi, and M. Cotrufo Aortic Arch Surgery: Thoracoabdominal Perfusion During Antegrade Cerebral Perfusion May Reduce Postoperative Morbidity Ann. Thorac. Surg., April 1, 2006; 81(4): 1358 - 1364. [Abstract] [Full Text] [PDF]

				K. Matsuura, H. Ogino, H. Matsuda, K. Minatoya, H. Sasaki, T. Yagihara, and S. Kitamura Surgical Outcome of Aortic Arch Repair for Patients With Takayasu Arteritis Ann. Thorac. Surg., January 1, 2006; 81(1): 178 - 182. [Abstract] [Full Text] [PDF]

				R. Turkoz, O. Gulcan, L. Oguzkurt, E. Caliskan, and A. Turkoz Successful Repair of Iatrogenic Acute Aortic Dissection With Cerebral Malperfusion Ann. Thorac. Surg., January 1, 2006; 81(1): 345 - 347. [Abstract] [Full Text] [PDF]

				D. Spielvogel, J. C. Halstead, M. Meier, I. Kadir, S. L. Lansman, R. Shahani, and R. B. Griepp Aortic Arch Replacement Using a Trifurcated Graft: Simple, Versatile, and Safe Ann. Thorac. Surg., July 1, 2005; 80(1): 90 - 95. [Abstract] [Full Text] [PDF]

				K. Morishita, N. Kawaharada, J. Fukada, Y. Kurimoto, Y. Fujisawa, T. Saito, and T. Abe Midterm Results of Surgical Treatment of Thoracic Aortic Disease in Dialysis Patients Ann. Thorac. Surg., July 1, 2005; 80(1): 96 - 100. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Marc A. A. M. Schepens Karl M. Dossche Teruhisa Kazui Roberto Di Bartolomeo Davide Pacini Angelo Pierangeli Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Di Eusanio, M. Articles by Pierangeli, A. Search for Related Content PubMed PubMed Citation Articles by Di Eusanio, M. Articles by Pierangeli, A. Related Collections Great vessels