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): David Spielvogel James C. Halstead Isaac Kadir Steven L. Lansman Rohit Shahani Randall B. Griepp Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Spielvogel, D. Articles by Griepp, R. B. Search for Related Content PubMed PubMed Citation Articles by Spielvogel, D. Articles by Griepp, R. B. Related Collections Great vessels

Ann Thorac Surg 2005;80:90-95
© 2005 The Society of Thoracic Surgeons

---

Original article: Cardiovascular

Aortic Arch Replacement Using a Trifurcated Graft: Simple, Versatile, and Safe

Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, New York

Accepted for publication February 1, 2005.

^_* Address reprint requests to Dr Halstead, Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, One Gustave L. Levy Place, New York, NY 10029 (Email: jameschalstead{at}yahoo.co.uk).

Presented at the Fifty-first Annual Meeting of the Southern Thoracic Surgical Association, Cancun, Mexico, Nov 2–4, 2004.

	Abstract

Top Abstract Introduction Patients and Methods Results Comment Discussion References

 
BACKGROUND: Hypothermic selective antegrade cerebral perfusion during aortic arch replacement may prevent adverse neurologic sequelae. It can be provided via balloon-tipped catheters or a branched graft sewn to the brachiocephalic vessels. We report a consecutive series of total arch replacement using a trifurcated graft.

METHODS: From September 1999 through October 2004, 109 patients underwent nonemergent total arch replacement using this technique. The graft, placed during a period of hypothermic circulatory arrest, was used for selective cerebral perfusion during the arch reconstruction.

RESULTS: Adverse outcomes were seen in 9 (8.3%) patients: hospital death in 5 (4.6%), and stroke in 5 (4.6%). Transient neurologic dysfunction was noted in 6 (5.5%) patients. Mean duration of hypothermic circulatory arrest was 31.2 ± 6.6 minutes and selective cerebral perfusion was 65.3 ± 20.9 minutes. Reoperation for bleeding was required in 3 (2.8%) patients and prolonged intubation in 15 (13.8%). Median intensive care unit stay was 3 days (interquartile range 2–4; range, 1 to 108) and hospital stay was 9 (interquartile range 8–15; range, 5 to 108).

CONCLUSIONS: The trifurcated graft technique results in low rates of perioperative mortality, temporary neurologic dysfunction, and stroke. It may reduce cerebral embolization as it requires no instrumentation of the aortic arch to establish selective cerebral perfusion and, although it mandates hypothermic circulatory arrest to place the graft, this interval is reliably brief enough to fall within accepted safe limits. This strategy leaves no residual arch tissue behind, and allows placement of an elephant trunk proximal to one or more arch vessels if anatomically indicated.

	Introduction

Top Abstract Introduction Patients and Methods Results Comment Discussion References

 
Total aortic arch replacement remains among the most challenging of aortic surgical procedures. Neurologic injury is the principal cause of serious morbidity and a factor in many perioperative deaths. Such insults can be either global or focal in nature. Global insults are believed to reflect generalized ischemia due to prolonged inadequate or absent perfusion. They can manifest as a spectrum of syndromes from subtle neuropsychiatric changes to profound coma. Focal brain injury is more likely due to the embolization of debris from the operative field [1, 2].

Antegrade selective cerebral perfusion (SCP), as an adjunct to hypothermic circulatory arrest (HCA) during arch reconstruction, is increasing in popularity, and seems to prevent many of the cerebral sequelae of global cerebral injury. It can be delivered in several ways, involving varying degrees of manipulation of the diseased arch and its branches; the method of implementation of SCP may therefore also impact focal cerebral injury rates. We present the results of a technique that uses a trifurcated graft, which is sewn to the divided brachiocephalic vessels cephalad to their diseased portions for SCP, and subsequently anastomosed to the aortic graft to complete the arch repair [3]. This trifurcated graft technique holds promise in lowering both the global and focal injury rates associated with aortic arch surgery, and solves a number of important technical problems associated with aortic arch replacement.

	Patients and Methods

Top Abstract Introduction Patients and Methods Results Comment Discussion References

 
Patient Data Abstraction
From our prospectively compiled database of patients undergoing aortic surgical procedures, we identified 109 consecutive patients (62 male, 47 female) who underwent nonemergent resection of aneurysms of the transverse aortic arch between September 1999 and October 2004, utilizing antegrade cerebral perfusion provided by a trifurcated graft. Clinical and operative details were obtained from the database and the patients’ medical records.

The mean patient age was 63.9 ± 14.4 years (range, 20 to 87). The most frequent etiology of the aneurysm was atherosclerosis, which was present in 41 patients (37.6%). Chronic dissection occurred in 35 (32.1%), and the aneurysms were classified as degenerative in 22 (20.2%). The remaining miscellaneous causes are detailed in Table 1. As noted in Table 2, 46 patients (42.2%) had undergone previous cardiac surgery. Not unexpectedly, a history of hypertension was noted in 91 patients (83.5%), of smoking in 57 (52.3%), and of coronary artery disease in 36 (33.0%).

The mean maximal diameter of the aorta was 6.2 ± 1.2 cm (range, 4.0 to 12.0). The extent of aortic replacement varied, and a number of patients had concomitant procedures. Lone aortic arch replacement was undertaken in 26 patients (23.9%). In addition, 55 patients (50.5%) had ascending aortic replacement; 17 (15.6%) had ascending aorta and aortic root replacement, and 3 (2.8%) had resection of the descending thoracic aorta. An elephant trunk was placed in 104 (95.4%) patients: distal to the L subclavian artery in 57 (52.3%); distal to the left carotid artery in 28 (25.7%); between the brachiocephalic and left carotid arteries in 6 (5.5%); and proximal to all arch branches in 13 (11.9%). Five patients (4.6%) had aortic valve replacement and 1 (0.9%) had a stent placed in the descending aorta. Coronary artery bypass grafting was performed in 25 patients (22.9%).

Operative Technique
A median sternotomy is performed with extension of the incision along the medial border of the left sternocleidomastoid muscle. The right axillary artery is exposed through an infraclavicular incision and cannulated with a right angle wire-reinforced cannula. Extracorporeal circulation and cooling are initiated after cannulation of the right atrium with a two-stage catheter. The perfusate temperature is maintained within 10°C of the esophageal temperature. During cooling, the aortic arch and brachiocephalic vessels are exposed, taking care to avoid their manipulation: in atherosclerotic aneurysms, these vessels, particularly the left subclavian artery, are not dissected until the period of circulatory arrest. A trifurcation graft is constructed by sewing two 8-mm branches to a 12-mm graft, or two 10-mm side branches to a 14-mm graft with 2-0 polypropylene suture. Alternatively, a commercially prepared graft is selected (Boston Scientific, Natick, MA). If the heart fibrillates during cooling, diastolic arrest is induced with the administration of potassium (1 mEq/kg) into the venous reservoir, and the left ventricle is vented through the right superior pulmonary artery. Thereafter, the patient is cooled until the jugular venous bulb saturation exceeds 95%, indicating optimal cerebral metabolic suppression. At this stage, if the heart is still beating the above measures are undertaken, and in addition the patient is placed in slight Trendelenburg position, the head is packed in ice, and circulatory arrest is begun.

The brachiocephalic vessels are transected about 1 cm distal to their origins, and dissection and mobilization are performed. At this level they are usually free from macroscopic atherosclerotic disease, but they can be trimmed a further centimeter or two to yield a cleaner vessel, if necessary. The arch vessels are sequentially sutured to the suitably trimmed graft with 5-0 polypropylene (Fig 1). The usual order is subclavian, left common carotid, and innominate arteries. After completion of these anastomoses, each is carefully aspirated through the limbs of the graft. Next, perfusion is slowly instituted via the axillary catheter to evacuate air from the brachiocephalic vessels and flush any debris retrograde. Perfusion is once more interrupted, and aspiration repeated. Then perfusion is restarted and the trifurcated graft is allowed to fill. Its proximal extent is clamped and selective perfusion to the head and upper extremities (SCP) is begun. Perfusion pressure (measured at the left radial artery) is maintained at 50–70 mm Hg, requiring flows of approximately 800–1,200 mL/min. Perfusate temperature is between 15 and 20°C.

View larger version (21K): [in this window] [in a new window]   Fig 1. Aortic arch resection using trifurcation graft reconstruction of the brachiocephalic vessels. (A) A typical aneurysm; (B) Division of the brachiocephalic vessels and aneurysm mobilization under HCA; (C) SCP via the trifurcated graft utilizing right axillary perfusion, and (D) the completed repair. (HCA = hypothermic circulatory arrest; SCP = selective cerebral perfusion.)

View larger version (27K): [in this window] [in a new window]   Fig 2. Four alternatives for placement of the elephant trunk anastomosis using the trifurcated graft technique: (A) distal to the left subclavian artery [57 patients]; (B) between subclavian and left common carotid arteries [28 patients]; (C) between left common carotid and innominate arteries [6 patients]; and (D) proximal to all arch vessels [13 patients]. Proximal placement may be of benefit when no appropriate distal neck exists because of extensive arch dilatation, or the recurrent laryngeal nerve cannot clearly be visualized.

Analysis of Results
Adverse outcome was defined as in-hospital death or perioperative stroke. Stroke was defined as a neurologic injury, which left the patient with a residual deficit at the time of hospital discharge.

Transient neurological dysfunction (TND) was assessed separately in those not experiencing a stroke, and was defined as postoperative confusion, agitation, delirium, prolonged obtundation or Parkinsonian symptoms. These patients had no evidence of new focal lesions on computed tomography or magnetic resonance imaging scans when such studies were available.

	Results

Top Abstract Introduction Patients and Methods Results Comment Discussion References

 
Intraoperative Findings
All arch reconstructions were completed using a single period of HCA followed by SCP utilizing the trifurcated graft technique. Mean duration of HCA was 31.2 ± 6.6 minutes (range, 17 to 48) at a mean esophageal temperature of 12.8 ± 2.2°C (range, 9.9 to 19.8). Mean duration of SCP was 65.3 ± 20.9 minutes (range, 21 to 113). The duration of cardiopulmonary bypass was 236.2 ± 52.5 minutes (range, 157 to 385).

Adverse Outcome
Adverse outcome was seen in 9 patients (8.3%). There were five hospital deaths (4.6%) and five permanent strokes (4.6%), one of which was fatal.

One patient who underwent arch and ascending aortic replacement died on the third postoperative day from right ventricular failure. Another patient, with severe chronic obstructive pulmonary disease, died on the tenth postoperative day from respiratory failure secondary to ventilator-associated pneumonia. A third patient also died on the tenth postoperative day with a large perioperative cerebrovascular accident, confirmed on a computed tomography scan. The fourth patient, who had undergone tracheostomy after inability to tolerate weaning from the respirator, died on day eighteen from dissection and subsequent rupture of the residual proximal aorta. The fifth patient, who was a cachectic current smoker, required surgery for a rapidly expanding atherosclerotic aneurysm and subsequently died on the thirty-fifth postoperative day from pulmonary hemorrhage and multiorgan failure.

Complications
The most frequent complication was respiratory; prolonged intubation (> 48 hours) was necessary in 15 (13.8%) patients. Transient neurologic dysfunction was noted in 6 patients (5.5%). Return to the operating room for control of postoperative hemorrhage was required in 3 patients (2.8%). Renal support with hemofiltration was needed in 4 patients (3.7%), but none had new permanent renal failure. Median intensive care unit stay was 3 days (interquartile range 2 to 4; range, 1 to 108) and hospital stay was 9 days (8 to 15; range, 5 to 108).

	Comment

Top Abstract Introduction Patients and Methods Results Comment Discussion References

 
Contemporary series [4–9] of total aortic arch replacements show increasingly impressive results, with low perioperative mortality rates and a low incidence of permanent neurologic injury (see Table 3). Undoubtedly these improvements are multifactorial in etiology. Increasing experience [7, 8], better perioperative patient care, and improved myocardial and cerebral protection have all contributed to improvements in outcome. However, no consensus exists as to the best conduct of these complex operations, especially with regard to cerebral protection [10].

Retrograde cerebral perfusion (RCP) through the superior vena cava has been advocated as a means of supplying the brain with oxygenated blood without instrumenting the aortic arch vessels or cluttering the operative field [17]. The RCP can also be used to keep the brain cool and may flush potentially embolic matter from the brachiocephalic vessels. Unfortunately, experimental studies have shown that very little brain perfusion results from this technique [18, 19] since most of the retrograde flow courses through various venous channels and anastomoses. These do include the dural sinuses [20], so it is likely that the principal benefit of this strategy is to enhance and maintain cerebral hypothermia. However, this can more simply be achieved with an adequate period of cooling on cardiopulmonary bypass prior to HCA, and local measures such as packing the head in ice.

Antegrade cerebral perfusion, apart from being the most physiological option, has established neurologic and metabolic benefits [21–23]. Its use in total arch replacement, or indeed any other arch resection where the systemic circulatory arrest period is anticipated to exceed 30 minutes, is well established. Its resurgence followed the recognition that hypothermia in conjunction with SCP enables use of lower flow rates and produces far superior results than cerebral perfusion at normothermia. Most recent large clinical series [4, 7–9] quote low incidences of temporary and permanent neurologic injury using hypothermic SCP.

Nevertheless, there remain important variations in the way SCP is delivered. Many surgeons feed flexible balloon-tipped catheters into the arch vessels under direct vision during a very brief period (1–3 minutes) of HCA, and achieve very good clinical results with this technique [7, 8]. Clearly, the optimal strategy for global cerebral protection and the ideal conditions for minimizing stroke may not be entirely compatible, and one must strike a balance between them to achieve the best results. Inserting catheters into the vessels for SCP minimizes HCA, and therefore reduces the incidence of global injury (as reflected by very low rates of TND with this technique), but risks embolization. One can maintain continual perfusion through the right axillary artery and clamp the innominate vessel proximally, and acceptable neurologic results with total arch replacement have been obtained with this methodology [24]. It avoids HCA entirely, but risks injury and embolization at the clamp site, as well providing variable perfusion to the left cerebral hemisphere dependent upon an intact circle of Willis.

In view of the often severe consequences of an embolic event, our philosophy has been to avoid all cerebral manipulation and clamping. We have adopted the strategy of transecting the cerebral vessels cephalad to their origins, and anastomosing them separately to a trifurcated graft, as reported herein. This technique avoids manipulation of the often-diseased vessel ostia, which may help prevent embolic stroke, but it does require HCA for longer periods than the balloon catheter and some other SCP techniques. However, the cephalad portions of the brachiocephalic vessels can reproducibly be attached to the trifurcated graft during a relatively short interval of HCA (a mean of 31 minutes in the current series) which most surgeons would consider well within safe limits at deeply hypothermic temperatures.

Technically, the branched graft operation does not require cluttering the field with multiple cannulae or monitoring multiple pumps, and is therefore suitable for use by surgeons who only occasionally are required to replace the aortic arch [25]. The small-diameter vessels can be anastomosed to the branches of the graft securely without reinforcement, as attested to by the very low incidence of reoperation for hemorrhage. In patients such as those with Marfan’s syndrome, the current procedure has the advantage over our previous technique [26] (in which a patch of aorta including all the cerebral vessels was left in situ) in removing all of the aneurysmal tissue in the arch, making recurrent arch aneurysm less likely. Also unique to this technique is the ability to site an elephant trunk graft proximally, in the midarch or in the ascending aorta. This is especially important in patients with dilatation of the arch and descending aorta, leaving no area of near normal diameter in which to anchor an elephant trunk more distally. Indeed, with this strategy the elephant trunk graft can even be placed as far proximally as the sinotubular junction. The graft is placed through the arch into the proximal descending aorta, the aorta is closed proximally incorporating the graft, and the brachiocephalic vessel origins are oversewn. Thus, the aortic arch remains pressurized until the descending aortic resection or stent insertion takes place.

Some uncertainty remains as to the optimal hemodynamic and perfusion parameters for SCP. Laboratory studies support the use of low temperatures for prolonged SCP, although some surgeons continue to feel that moderately hypothermic SCP may be preferable. Most series report mean perfusion pressures of about 50 mm Hg, with flow rates of approximately 10 mL· kg·min. Whether higher perfusion pressures might be advantageous in these often elderly, vasculopathic patients, or deleterious because of the risk of increased delivery of emboli, remains open. Questions regarding optimal pH strategy, and whether higher hematocrits than those used currently would be beneficial, are still being argued [27]. The resolution of these issues will require careful clinical and experimental studies, and should lead to further improvements in this challenging field.

At present, the optimal cerebral protection strategy for total arch replacement would seem to be one relying on hypothermic antegrade SCP. The present series illustrates that use of a trifurcation graft to the brachiocephalic vessels is a simple, reliable, and safe method for aortic arch replacement.

	Discussion

Top Abstract Introduction Patients and Methods Results Comment Discussion References

 
DR JOHN H. CALHOON (San Antonio, TX): As you move the site of the elephant trunk anastomosis, do you increase the propensity for rupture between the first and second procedure, and what was your incidence of rupture or do you have that recorded between the first and second procedure?

DR HALSTEAD: We have had a few cases that have ruptured in between first-stage and second-stage elephant trunk procedures, but they have actually been patients who have ruptured their descending thoracic aortic aneurysms. There haven’t been any patients who have had rupture of arches that we have retained pressurization in following the first stage.

	References

Top Abstract Introduction Patients and Methods Results Comment Discussion References

 

1. Griepp RB, Ergin MA, McCullough JN, et al. Use of hypothermic circulatory arrest for cerebral protection during aortic surgery J Card Surg 1997;12(suppl 2):312-321.[Medline]
2. Hagl C, Ergin MA, Galla JD, et al. Neurologic outcome after ascending aorta-aortic arch operationseffect of brain protection technique in high-risk patients. J Thorac Cardiovasc Surg 2001;121:1107-1121.[Abstract/Free Full Text]
3. 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;74:S1810-S1814.[Abstract/Free Full Text]
4. Di Eusanio M, Schepens MAAM, Morshuis WJ, et al. Separate grafts or en bloc anastomosis for arch vessels reimplantation to the aortic arch Ann Thorac Surg 2004;77:2021-2028.[Abstract/Free Full Text]
5. Ueda Y, Okita Y, Aomi S, Koyanagi H, Takamoto S. Retrograde cerebral perfusion for aortic arch surgeryanalysis of risk factors. Ann Thorac Surg 1999;67:1879-1882.[Abstract/Free Full Text]
6. Numata S, Ogino H, Sasaki H, et al. Total arch replacement using antegrade selective cerebral perfusion with right axillary artery perfusion Eur J Cardiothorac Surg 2003;23:771-775.[Abstract/Free Full Text]
7. Kazui T, Washiyama N, Muhammad BAH, et al. Total arch replacement using aortic arch branched grafts with the aid of antegrade selective cerebral perfusion Ann Thorac Surg 2000;70:3-9.[Abstract/Free Full Text]
8. Kazui T, Yamashita K, Washiyama N, et al. Usefulness of antegrade selective cerebral perfusion during aortic arch operations Ann Thorac Surg 2002;74:S1806-S1809.[Abstract/Free Full Text]
9. Bachet J, Guilmet D, Goudot B, et al. Antegrade cerebral perfusion with cold blooda 13-year experience. Ann Thorac Surg 1999;67:1874-1878.[Abstract/Free Full Text]
10. Matalanis G, Hata M, Buxton BF. A retrospective comparative study of deep hypothermic circulatory arrest, retrograde, and antegrade cerebral perfusion in aortic arch surgery Ann Thorac Cardiovasc Surg 2003;9:174-179.[Medline]
11. De Bakey ME, Crawford ES, Cooley DA, Morris Jr. GC. Successful resection of fusiform aneurysm of aortic arch with replacement by homograft Surg Gynaecol Obstet 1957;105:657-664.
12. Pearce CW, Wiechert RF, Del Real RE. Aneurysms of aortic arch. Simplified technique for excision and prosthetic replacement J Thorac Cardiovasc Surg 1969;58:886-890.[Medline]
13. Griepp RB, Stinson EB, Hollingsworth JF, Buehler D. Prosthetic replacement of the aortic arch J Thorac Cardiovasc Surg 1975;70:1051-1063.[Abstract]
14. Antunes MJ, Colsen PR, Kinsley RH. Hypothermia and circulatory arrest for surgical resection of aortic arch aneurysms J Thorac Cardiovasc Surg 1983;86:576-581.[Abstract]
15. Ergin MA, Galla JD, Lansman SL, et al. Hypothermic circulatory arrest in operations of the thoracic aortadeterminants of operative mortality and neurological outcome. J Thorac Cardiovasc Surg 1994;107:788-799.[Abstract/Free Full Text]
16. Ehrlich MP, Ergin MA, McCullough JN, et al. Predictors of adverse outcome and transient neurological dysfunction after ascending aorta/hemiarch replacement Ann Thorac Surg 2000;69:1755-1763.[Abstract/Free Full Text]
17. Ueda Y, Miki S, Kusuhara K, Okita Y, Tahata T, Yamanaka K. Deep hypothermic systemic circulatory arrest and continuous retrograde cerebral perfusion for surgery of aortic arch aneurysm Eur J Cardiothoracic Surg 1992;6:36-41.[Abstract]
18. Ehrlich MP, Hagl C, McCullough JN, et al. Retrograde cerebral perfusion provides negligible flow through brain capillaries in the pig J Thorac Cardiovasc Surg 2001;122:331-338.[Abstract/Free Full Text]
19. Duebener LF, Hagino I, Schmitt K, et al. Direct visualization of minimal cerebral capillary flow during retrograde cerebral perfusionan intravital fluorescence microscopy study in pigs. Ann Thorac Surg 2003;75:1288-1293.[Abstract/Free Full Text]
20. de Brux JL, Subayi JB, Pegis JD, Pillet J. Retrograde cerebral perfusionanatomic study of the distribution of blood to the brain. Ann Thoracic Surg 1995;60:1294-1298.[Abstract/Free Full Text]
21. Crittenden MD, Roberts CS, Rosa L, et al. Brain protection during circulatory arrest Ann Thorac Surg 1991;51:942-947.[Abstract]
22. Robbins RC, Balaban RS, Swain JA. Intermittent hypothermic asanguinous cerebral perfusion (cerebroplegia) protects the brain during prolonged circulatory arrest. A phosphorus 31 nuclear magnetic resonance study J Thorac Cardiovasc Surg 1990;99:878-884.[Abstract]
23. Higami T, Kozawa S, Asada T, et al. Retrograde cerebral perfusion versus selective cerebral perfusion as evaluated by cerebral oxygen saturation during aortic arch reconstruction Ann Thorac Surg 1999;67:1091-1096.[Abstract/Free Full Text]
24. Wozniak G, Dapper F, Zickmann B, Gehron J, Hehrlein FW. Selective cerebral perfusion via innominate artery in aortic arch replacement without deep hypothermic circulatory arrest Int J Angiol 1999;8:50-56.[Medline]
25. Sundt TM, Moon MR, DeOliviera N, McDonald J, Camillo CJ, Pasque MK. Contemporary results of total aortic arch replacement J Card Surg 2004;19:235-239.[Medline]
26. Strauch JT, Spielvogel D, Lauten A, et al. Technical advances in total aortic arch replacement Ann Thorac Surg 2004;77:581-590.[Abstract/Free Full Text]
27. Ohkura K, Kazui T, Yamamoto S, et al. Comparison of pH management during antegrade selective cerebral perfusion in canine models with old cerebral infarction J Thorac Cardiovasc Surg 2004;128:378-385.[Abstract/Free Full Text]
28. Okita Y, Minatoya K, Tagusari O, Ando M, Nagatsuka K, Kitamura S. Prospective comparative study of brain protection in total aortic arch replacementdeep hypothermic circulatory arrest with retrograde cerebral perfusion or selective antegrade cerebral perfusion. Ann Thorac Surg 2001;72:72-79.[Abstract/Free Full Text]

This article has been cited by other articles:

				J. G.T. Augoustides Optimizing selective cerebral perfusion in adult aortic arch repair: clinical relevance of the laboratory model. J. Thorac. Cardiovasc. Surg., October 1, 2008; 136(4): 1105 - 1106. [Full Text] [PDF]

				A. L. Estrera, C. C. Miller III, T.-Y. Lee, P. Shah, and H. J. Safi Ascending and Transverse Aortic Arch Repair: The Impact of Retrograde Cerebral Perfusion Circulation, September 30, 2008; 118(14_suppl_1): S160 - S166. [Abstract] [Full Text] [PDF]

				C. D. Etz, K. A. Plestis, F. A. Kari, M. Luehr, C. A. Bodian, D. Spielvogel, and R. B. Griepp Staged repair of thoracic and thoracoabdominal aortic aneurysms using the elephant trunk technique: a consecutive series of 215 first stage and 120 complete repairs Eur. J. Cardiothorac. Surg., September 1, 2008; 34(3): 605 - 615. [Abstract] [Full Text] [PDF]

				J. P. Schwartz, M. Bakhos, A. Patel, S. Botkin, and S. Neragi-Miandoab Repair of aortic arch and the impact of cross-clamping time, New York Heart Association stage, circulatory arrest time, and age on operative outcome Interactive CardioVascular and Thoracic Surgery, June 1, 2008; 7(3): 425 - 429. [Abstract] [Full Text] [PDF]

				N. Khaladj, M. Shrestha, S. Meck, S. Peterss, H. Kamiya, K. Kallenbach, M. Winterhalter, L. Hoy, A. Haverich, and C. Hagl Hypothermic circulatory arrest with selective antegrade cerebral perfusion in ascending aortic and aortic arch surgery: A risk factor analysis for adverse outcome in 501 patients. J. Thorac. Cardiovasc. Surg., April 1, 2008; 135(4): 908 - 914. [Abstract] [Full Text] [PDF]

				S. A. LeMaire and J. S. Coselli Reply Ann. Thorac. Surg., February 1, 2008; 85(2): 691 - 692. [Full Text] [PDF]

				T. Kunihara, N. Shiiya, K. Matsuzaki, and Y. Matsui Metabolic relevance during isolation technique in total arch repair for patients at high risk with embolic stroke Interactive CardioVascular and Thoracic Surgery, February 1, 2008; 7(1): 58 - 62. [Abstract] [Full Text] [PDF]

				D. Spielvogel, M. N. Mathur, and R. B. Griepp Aneurysms of the Aortic Arch Card. Surg. Adult, January 1, 2008; 3(2008): 1251 - 1276. [Full Text]

				J. C. Halstead, C. Etz, D. M. Meier, N. Zhang, D. Spielvogel, D. Weisz, C. Bodian, and R. B. Griepp Perfusing the Cold Brain: Optimal Neuroprotection for Aortic Surgery Ann. Thorac. Surg., September 1, 2007; 84(3): 768 - 774. [Abstract] [Full Text] [PDF]

				M. Di Eusanio, M. Ciano, G. Labriola, G. Lionetti, and G. Di Eusanio Cannulation of the innominate artery during surgery of the thoracic aorta: our experience in 55 patients Eur. J. Cardiothorac. Surg., August 1, 2007; 32(2): 270 - 273. [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]

				H. Sasaki, H. Ogino, H. Matsuda, K. Minatoya, M. Ando, and S. Kitamura Integrated Total Arch Replacement Using Selective Cerebral Perfusion: A 6-Year Experience Ann. Thorac. Surg., February 1, 2007; 83(2): S805 - S810. [Abstract] [Full Text] [PDF]

				R. B. Griepp and E. B. Griepp Spinal Cord Perfusion and Protection During Descending Thoracic and Thoracoabdominal Aortic Surgery: The Collateral Network Concept Ann. Thorac. Surg., February 1, 2007; 83(2): S865 - S869. [Abstract] [Full Text] [PDF]

				P. Merkkola, H. Tulla, A. Ronkainen, V. Soppi, A. Oksala, T. Koivisto, and M. Hippelainen Incomplete circle of willis and right axillary artery perfusion. Ann. Thorac. Surg., July 1, 2006; 82(1): 74 - 79. [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]

				T. Kazui and A. H. M. Bashar Aortic Arch Replacement Using a Trifurcated Graft Ann. Thorac. Surg., April 1, 2006; 81(4): 1552 - 1552. [Full Text] [PDF]

				G. Silvay and M. E. Stone Repair of Thoracic Aneurysms, with Special Emphasis on the Preoperative Work-Up Seminars in Cardiothoracic and Vascular Anesthesia, March 1, 2006; 10(1): 11 - 15. [Abstract] [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): David Spielvogel James C. Halstead Isaac Kadir Steven L. Lansman Rohit Shahani Randall B. Griepp Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Spielvogel, D. Articles by Griepp, R. B. Search for Related Content PubMed PubMed Citation Articles by Spielvogel, D. Articles by Griepp, R. B. Related Collections Great vessels