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): Hitoshi Ogino Hitoshi Matsuda Kenji Minatoya Motomi Ando Soichiro Kitamura Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Sasaki, H. Articles by Kitamura, S. Search for Related Content PubMed PubMed Citation Articles by Sasaki, H. Articles by Kitamura, S. Related Collections Great vessels

Ann Thorac Surg 2007;83:S805-S810
© 2007 The Society of Thoracic Surgeons

---

Supplement

Integrated Total Arch Replacement Using Selective Cerebral Perfusion: A 6-Year Experience

^a Department of Cardiovascular Surgery, National Cardiovascular Center, Osaka
^b Department of Thoracic Surgery, Fujita Health University, Aichi, Japan

^_* Address correspondence to Dr Sasaki, Department of Cardiovascular Surgery, National Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka 565-8565, Japan. (Email: hmsasaki{at}hsp.ncvc.go.jp).

Presented at Aortic Surgery Symposium X, New York, NY, April 27–28, 2006.

	Abstract

Top Abstract Introduction Patients and Methods Results Comment References

 
BACKGROUND: The purpose of this study was to evaluate the recent outcome of integrated total arch replacement using antegrade selective cerebral perfusion with right axillary artery perfusion.

METHODS: Between 2000 and 2005, 305 patients underwent elective total arch replacement for arch or distal arch aneurysm using a Dacron (DuPont, Wilmington, DE) quadrifurcated prosthesis through a median sternotomy. There were 34 dissecting and 271 nondissecting aneurysms. Brain protection was standardized using antegrade selective cerebral perfusion with right axillary artery cannulation at 20° to 28°C. Risk factors for early mortality and neurologic complications were investigated using multivariate logistic regression analyses.

RESULTS: The durations of hypothermic circulatory arrest, myocardial ischemia, selective cerebral perfusion, cardiopulmonary bypass, and surgery were 60.9 ± 16.8, 125.2 ± 39.3, 150.1 ± 39.0, 229.8 ± 91.4, and 466.4 ± 175.8 minutes, respectively. Seven patients died, for a 2.3% early mortality. Permanent neurologic dysfunction developed in 5 patients (1.6%), and temporary neurologic dysfunction in 20 (6.6%). The mid-term survival rate was 94.6% ± 1.5% at 3 years. On multivariate analyses, prolonged surgery was a risk factor for early mortality. Preoperative cerebral hypoperfusion was a significant determinant for temporary neurologic dysfunction and male gender for permanent neurologic dysfunction.

CONCLUSIONS: Integrated total arch replacement using antegrade selective cerebral perfusion with right axillary artery cannulation yields a favorable outcome with low mortality and cerebral morbidity rates.

	Introduction

Top Abstract Introduction Patients and Methods Results Comment References

 
Total arch replacement (TAR) for arch-to-distal arch aneurysms still has surgically challenging aspects and features high mortality and morbidity [1, 2]. In particular, postoperative neurologic complications resulting in mortality or other morbidities remain prevalent, although great progress in brain protection has recently been achieved [1–7]. We have changed our technique of brain protection from retrograde cerebral perfusion (RCP) [5, 6, 8] with profound hypothermia to antegrade selective cerebral perfusion (SCP) [2–4] combined with right axillary artery cannulation [9]. In the present study, the recent outcome of integrated TAR using SCP with right axillary artery cannulation is reviewed, and relevant risk factors for early mortality and cerebral morbidity are examined.

	Patients and Methods

Top Abstract Introduction Patients and Methods Results Comment References

 
Patients
A retrospective review was performed of 305 patients (238 men) undergoing elective TAR for arch or distal arch aneurysm between 2000 and 2005 in the National Cardiovascular Center, Osaka, Japan. Median patient age was 73 years (range, 52 to 87 years). There were 34 dissecting and 271 nondissecting aneurysms. The cause of the aneurysm was atherosclerotic in 289 patients, non-Marfan degenerative in 10 patients, Marfan in 2 patients, and aortitic (including Behçet disease) in 4 patients. Ten patients requiring reoperative surgery were included. Also included were 18 patients with extensive thoracic aortic aneurysm involving the arch; for them, two-stage surgery was performed with stage I TAR, followed by stage II descending aortic replacement in 12 patients and endoluminal stent grafting in 6 older patients with respiratory dysfunction. Institutional approval for this study was obtained, and each patient in the study gave informed consent to serve as a subject.

Surgical Techniques and Brain Protection
All aneurysms were approached through a median sternotomy and replaced using a quadrifurcated Dacron (DuPont, Wilmington, DE) prosthesis with open distal anastomosis.

1 Cardiopulmonary bypass (CPB) establishment with right axillary artery perfusion. In the last decade, we have refined surgical techniques, including strategies of CPB, brain protection, and lowest core temperature (Fig 1). Since 2000, right axillary artery perfusion has been routinely used in conjunction with femoral artery or ascending aorta cannulation for CPB to prevent cerebral emboli caused by retrograde femoral artery perfusion and for quick and easy conversion to SCP (Fig 2) [9].
The right axillary artery is exposed through a 5-cm to 7-cm incision in the right armpit. After full heparinization, a 10F to 16F straight thin-walled cannula is inserted into the right axillary artery. Empirically, 12F cannulae produce up to 1500 mL/min flow for CPB. Right axillary artery perfusion is initiated to prevent cerebral emboli before femoral artery perfusion. Bicaval venous drainage with left ventricular venting is routine.

2 Brain protection using SCP with right axillary artery perfusion. Before 2000, RCP with deep hypothermia at 16° to 18°C was predominantly used for brain protection (Fig 1) [5, 6]. Since the beginning of 2000, we have routinely used the current method of SCP combined with right axillary artery perfusion [9]. After induction of hypothermic circulatory arrest (HCA), SCP through right axillary artery perfusion is commenced by clamping the brachiocephalic (innominate) artery. The transverse arch is opened, and a 12F SCP balloon-tipped cannula is inserted from within the aorta into the left common carotid artery.
Between 2000 and 2002, SCP was instituted by right axillary artery and left common carotid artery perfusion, with the left subclavian artery clamped, at 20° to 23°C. During SCP, the bilateral superficial temporal artery pressures or the pressures of the balloon tips were monitored and maintained in the range of 30 to 50 mm Hg. Subsequently, SCP flows were about 10 mL/(kg · min), generated by a single roller pump separate from the systemic circulation (Fig 2). In 2003, left subclavian artery perfusion using another balloon-tip cannula was added, and the lowest core temperature was gradually increased to 25° or 28°C. SCP flow is also increased to maintain perfusion pressure between 50 and 70 mm Hg (800 to 1200 mL/min). Cardiac arrest is induced by antegrade and retrograde cardioplegia.

3 Stepwise distal anastomosis (Fig 3). Through the aneurysm, the proximal descending aorta distal to the aneurysm is transected completely to prevent phrenic and vagal nerve injury. Open distal anastomosis is performed during HCA of the lower half of the body. Before 2000, a quadrifurcated arch graft was directly anastomosed to the descending aorta with 3-0 or 4-0 polypropylene continuous suture. Since 2000, stepwise distal anastomosis has been used for an easy and secure anastomosis [10, 11] with routine right axillary artery perfusion.

View larger version (34K): [in this window] [in a new window]   Fig 1. Refinement of cardiopulmonary bypass (CPB), brain protection, and body (core) temperature (BT). (FA = femoral artery; Asc.Ao = ascending aorta; AxA = axillary artery; SCP = antegrade selective cerebral perfusion; RCP = retrograde cerebral perfusion.)

View larger version (43K): [in this window] [in a new window]   Fig 2. A two-pump system for cardiopulmonary bypass (CPB) and antegrade selective cerebral perfusion (SCP).

View larger version (40K): [in this window] [in a new window]   Fig 3. Integrated total arch replacement using antegrade selective cerebral perfusion with right axillary artery perfusion. (1) Arch or distal arch aneurysm. (2) Ascending aorta and right axillary artery cannulation for cardiopulmonary bypass. (3) Induction of hypothermic circulatory arrest with the arch vessels clamped. (4) Selective cerebral perfusion with right axillary artery, left common carotid artery, left subclavian artery perfusion. (5) Original stepwise technique. (6) Refined stepwise technique with mini-elephant trunk. (7) Distal anastomosis. (8) Graft-to-graft anastomosis. (9) Total arch replacement using quadrifurcated graft. Circled numbers show the turn of the anastomosis.

Systemic circulation is resumed using a branch of the arch graft. The left subclavian artery is initially reconstructed using a branch graft, and the patient is slowly rewarmed to 30°C. The proximal aortic anastomosis follows, above the sinotubular junction, using 4-0 polypropylene running suture. Coronary circulation is initiated by unclamping the aorta. The other two arch vessels are finally reconstructed with branch grafts.

Definition of Neurologic Deficits and Other Variables
Permanent neurologic dysfunction (PND) was defined as the presence of permanent neurologic deficits either focal or global in nature, persisting at discharge. Transient neurologic dysfunction (TND) was defined as the occurrence of postoperative confusion, agitation, delirium, or prolonged obtundation [12]. Cerebral hypoperfusion was defined as the preoperative presence of more than 50% stenosis of the arch vessels or the intracranial vessels, or both, on echo or magnetic resonance angiography study, or hypoperfusion on acetazolamide-loading cerebral flow scintigraphy.

Data Collection and Statistical Analysis
Medical records were reviewed for clinical variables including preoperative status, intraoperative data, postoperative complications, and mid-term survival. Follow-up was 100% complete. The mean follow-up period was 31.0 ± 19.6 months. We retrospectively reviewed the overall outcome of TAR and investigated risk factors for hospital mortality and cerebral morbidity by multivariate logistic regression analyses.

Statistical analysis was done with SPSS software (SPSS Inc, Chicago, IL). Values are expressed as the mean ± standard deviation or medians (range), with values of p < 0.05 considered significant. Logistic regression was used to investigate risk factors for mortality and cerebral morbidity. Kaplan-Meier estimates were used to calculate survival rates.

	Results

Top Abstract Introduction Patients and Methods Results Comment References

 
The mean of the lowest nasopharyngeal temperature was 23.1° ± 3.7°C. The durations of hypothermic circulatory arrest for open distal anastomosis, myocardial ischemia, SCP, CPB, and surgery were 60.9 ± 16.8, 125.2 ± 39.3, 150.1 ± 39.0, 229.8 ± 91.4, and 466.4 ± 175.8 minutes, respectively. No patients died within 24 hours after surgery; however, 6 patients (1.9%) died within 30 days after surgery from low output syndrome in 1 patient, respiratory failure due to pulmonary bleeding in 1, sepsis (mediastinitis) in 2 [1] patients, and bowel necrosis in 2 patients. Four months after surgery, another 84-year-old patient died from sepsis caused by stent graft infection after a second procedure that followed TAR during the same hospitalization. Thus, there were 7 (2.3%) early deaths. PND developed in 5 (1.6%) patients and TND developed in 20 (6.6%). The mid-term survival rate was 94.6 ± 1.5% at 3 years (Fig 4).

View larger version (9K): [in this window] [in a new window]   Fig 4. Mid-term survival (Kaplan-Meier estimates).

	Comment

Top Abstract Introduction Patients and Methods Results Comment References

 
Great advances in TAR commenced with the induction of RCP with profound HCA in 1993 [5, 6, 8]. This widely accepted adjunct improved overall outcome remarkably [12–16]. However, many patients still sustained TND, especially after prolonged HCA even with RCP [5, 6, 13–16], although Okita and colleagues [5] at our institute reported no difference. Reich and colleagues [17] reported that profound HCA exceeding 25 minutes and advanced age were associated with memory and fine motor deficits and prolonged hospital stay. The incidence and severity of TND correlates with poor performance on neuropsychologic testing, which predicts continued deficits in memory and motor function [18]. To decrease TND, we switched our strategy for brain protection from RCP to SCP, which is basically physiologic and has a longer cerebral safety margin. Since the beginning of 2000, we have consistently performed SCP for brain protection [9].

With SCP, however, atheromatous cerebral emboli remain a major concern. A variety of embolic phenomena are caused by systemic CPB perfusion through the ascending aorta across the arch aneurysm or by retrograde femoral artery perfusion. Arch vessel cannulation also carries a risk of cerebral embolization [17, 18]. For these reasons, an alternative perfusion pathway using the right axillary artery has been routinely used for both CPB and SCP [9].

The right axillary artery can easily be exposed and cannulated and is less atherosclerotic than the arch. Unfortunately, in Japanese patients, particularly small women, the axillary artery is too small to accept larger-size cannulae, so that additional cannulation through the femoral artery or the ascending aorta is necessary for systemic CPB flow. Femoral artery cannulation was previously performed. Retrograde femoral artery perfusion was useful not only for flushing out debris in the descending aorta but also to check for bleeding from the key distal anastomosis in the descending aorta.

The combination of right axillary artery and femoral artery perfusion was used for approximately 3 years, between 2000 and 2002, and we have previously reported its advantages [9]. With this combination, downstream flow through the right axillary artery can compete with retrograde femoral artery perfusion in the descending aorta and may prevent cerebral emboli. However, in the absence of atherosclerosis, ascending aorta cannulation, which yields antegrade CPB flow, has become our first choice rather than femoral artery perfusion [19].

We believe that right axillary artery cannulation is of use even with ascending aorta cannulation because the switch from systemic perfusion by way of CPB to SCP is easy, with no discontinuity, and cannulation-induced emboli from the brachiocephalic artery can be avoided. We have therefore been able to increase core temperature to 28°C [20]. If the ascending aorta is atherosclerotic, however, the femoral artery is chosen as an alternative site of cannulation.

We have thus continued integrated TAR using SCP with right axillary artery perfusion in the last 6 years. In this study, the early and mid-term outcomes were reviewed, with assessment of significant determinants for mortality and cerebral morbidity. Our integrated TAR yielded a satisfactory 2.3% early mortality rate, even with difficult surgery including a two-stage repair of extensive thoracic aortic aneurysms involving the arch, and even for elderly individuals with a median age of 73 years. The current outcome is comparable or superior to those described in previous reports [21–23].

Multivariate analysis demonstrated that only prolonged surgery was an independent determinant of early death. In contrast, Kazui and colleagues [3] reported that chronic renal failure, long CPB time (>300 minutes), participation in an early series, and shock were risk factors for death in their first study, and PND in a more recent study [4]. No other factors such as age, coexisting coronary artery disease, reoperative surgery, dissection, neurologic comorbidities, postoperative neurologic complications, or concomitant surgery including coronary artery bypass or root surgery were significant predictors of early mortality.

Preoperatively, 30.2% of the patients had coexisting coronary artery disease. The strategy for treatment of coronary artery disease associated with arch aneurysms is still controversial. Cardiologists tend to suggest safer catheter intervention before TAR because TAR has a high mortality risk and most patients who need TAR are old. Conversely, prompt performance of combined TAR with coronary artery bypass grafting (CABG) is recommended by surgeons because CABG is can be performed concomitantly with a low risk. In the present series, TAR and CABG were performed together in 62 patients, 3 of whom died, yielding a mortality rate of 4.8%. The causes of death were unrelated to coronary artery disease: bowel necrosis in 2 patients and mediastinitis in 1. We therefore believe that use of combined TAR with CABG is justified.

Ergin and colleagues [12, 18] reported that postoperative cerebral morbidity after TAR remains a major problem resulting in mortality and serious morbidity. The present study did not yield similar results. Multivariate analysis revealed preoperative cerebral hypoperfusion—including old cerebral infarction—to be a risk factor for TND, although it was not an independent predictor for PND. This finding was expected. TND is considered to be due to cerebral hypoperfusion during CPB, or HCA with selective or retrograde cerebral perfusion [12]. Conversely, most strokes are considered due to embolism originating from hematoma or atheroma in the aorta or in the arch vessels [12]. For patients with cerebral hypoperfusion before surgery, our strategies were modified to include higher CPB perfusion pressure (>60 mm Hg), more profound hypothermia (20° to 22°C), and higher SCP flow rates, with increases in SCP pressure of 20% to 30%. These refinements yielded good outcomes empirically.

On multivariate analysis, male gender was the only significant determinant of PND. As mentioned, the cause of PND is believed to be emboli caused by atheroma in the ascending aorta/aortic arch and in the arch vessels, particularly under well-established brain protection, whether in conjunction with RCP or SCP [12]. In the present series, 78.0% of the 305 patients were men, and all patients who sustained PND were men. Male gender is widely considered a risk factor for atherosclerotic change in all arteries. This finding was therefore also expected.

The degree of atheromatous change was not assessed in this study, although atherosclerotic aneurysm was evaluated as a potential risk factor. It is of interest that the Mt. Sinai group [7] assessed clot/atheroma as a risk factor for adverse outcome including cerebral complications; however, it is difficult to quantitatively evaluate the degree or amount of atheromatous lesions.

For patients with severe atheromatous lesions in the arch vessels or their orifices, adequate brain protection technique is still controversial. RCP has been criticized because prolonged HCA results in cerebral morbidity [5, 6, 13–15], whereas SCP theoretically has a longer cerebral safety margin [2–4]. However, SCP—requiring cannulation of the arch vessels—has the potential for cerebral embolism, which has been considered its worst shortcoming [8, 12].

In our strategy involving right axillary artery cannulation, we can avoid cannulation of the brachiocephalic artery, which sometimes exhibits atheromatous change. Fortunately, the left common carotid artery is generally less atheromatous, making its cannulation easy and safe. Cannulation of the left subclavian artery is sometimes dangerous because it often has the most severe atheromatous changes of the three arch vessels. In these situations, cannulation must be carefully performed, or patients must be cooled to below 22° to 23°C and the left subclavian artery left uncannulated.

Atheroma in the ascending aorta and the aortic arch is another potential source of emboli to the brain. Atheromatous change in the ascending aorta and the arch should be assessed by preoperative computed tomography or epiaortic echo examination, and ascending aortic cannulation for CPB should be carefully performed. The impact of right axillary artery perfusion on cerebral safety in TAR has been elucidated in this study.

In addition, since 2000 we have used a unique stepwise technique for easy and secure anastomosis [11, 12]. With this technique, distal anastomosis has become much easier, with good exposure of the anastomosis site even in difficult aneurysms extending distally. In TAR through a median approach, the distal anastomosis is a key aspect. One shortcoming of the stepwise anastomosis is the need for another graft-to-graft anastomosis, but this normally takes only 5 to 10 minutes. Another is the possibility of dislodgement of atheroma in the descending aorta. One patient who experienced bowel necrosis a few days after surgery required resection of the gut. However, we believe the stepwise anastomosis technique is useful and safe overall, particularly for aneurysms extending distally, and consequently will improve the overall outcome of integrated TAR with SCP and right axillary artery perfusion. The recent outcome of integrated TAR using SCP with right axillary artery cannulation was satisfactory, with low hospital mortality and cerebral morbidity rates.

	References

Top Abstract Introduction Patients and Methods Results Comment References

 

1. Bachet J, Guilmet D, Goudout B, et al. Antegrade cerebral perfusion in operations on the proximal thoracic aorta Ann Thorac Surg 1999;67:1874-1878.[Abstract/Free Full Text]
2. Kazui T, Washiyama N, Muhammad BA, 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]
3. Kazui T, Washiyama N, Muhammad BA, 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]
4. 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]
5. Okita Y, Takamoto S, Ando M, Morota T, Matsukawa R, Kawashima Y. Mortality and cerebral outcome in patients who underwent aortic arch operations using deep hypothermic circulatory arrest with retrograde cerebral perfusion: no relation of early death, stroke, and delirium to the duration of circulatory arrest J Thorac Cardiovasc Surg 1998;115:129-138.[Abstract/Free Full Text]
6. Okita Y, Ando M, Minatoya K, Kitamura S, Takamoto S, Nakajima N. Predictive factors for mortality and cerebral complications in atherosclerotic aneurysm of the aortic arch Ann Thorac Surg 1999;67:72-78.[Abstract/Free Full Text]
7. Strauch JT, Spielvogel D, Griepp RB, et al. Technical advances in total arch aortic replacement Ann Thorac Surg 2004;77:581-590.[Abstract/Free Full Text]
8. Ueda Y, Miki S, Ogino H, et al. Protective effect of continuous retrograde cerebral perfusion on the brain during deep hypothermic systemic circulatory arrest J Cardiac Surg 1994;9:584-595.[Medline]
9. Numata S, Ogino H, Ando M, et al. Total arch replacement using antegrade selective cerebral perfusion with right axillary artery perfusion Euro J Cardiothorac Surg 2003;23:771-775.[Abstract/Free Full Text]
10. Ogino H, Ando M, Sasaki H, Minatoya K. Total arch replacement using a stepwise distal anastomosis for arch aneurysms with distal extension Eur J Cardiothorac Surg 2006;29:255-257.[Abstract/Free Full Text]
11. Minatoya K, Ogino H, Matsuda H, Sasaki H, Yagihara T, Kitamura S. Surgical management of distal arch aneurysm: another approach with improved results Ann Thorac Surg 2006;81:1353-1357.[Abstract/Free Full Text]
12. Ergin MA, Galla JD, Lansman SL, Quintann C, Bodian C, Griepp RB. Hypothermic circulatory arrest in operations on the thoracic aorta: determinants of operative mortality and neurologic outcome J Thorac Cardiovasc Surg 1994;107:788-799.[Abstract/Free Full Text]
13. Coselli JS, LeMaire SA. Experience with retrograde cerebral perfusion during proximal aortic surgery in 290 patients J Card Surg 1997;12(Suppl):322-325.[Medline]
14. Bavaria JE, Pochettino A. Retrograde cerebral perfusion in aortic arch surgery: efficacy and possible mechanisms of brain protection Semin Thorac Cardiovasc Surg 1997;9:222-232.[Medline]
15. Usui A, Abe T, Murase M. Early clinical results of retrograde cerebral perfusion for aortic arch operations in Japan Ann Thorac Surg 1996;62:94-104.[Abstract/Free Full Text]
16. Ogino H, Ueda Y, Sugita T, et al. Monitoring of regional cerebral oxygenation by near-infrared spectroscopy during continuous retrograde cerebral perfusion for aortic arch surgery Euro J Cardiothorac Surg 1998;14:415-418.[Abstract/Free Full Text]
17. Reich DL, Uysal S, Griepp RB, et al. Neuropsychologic outcome after deep hypothermic circulatory arrest in adults J Thorac Cardiovasc Surg 1999;177:156-163.
18. Ergin MA, Uysal S, Griepp RB, et al. Temporary neurological dysfunction after deep hypothermic circulatory arrest: a clinical marker of long-term functional deficit Ann Thorac Surg 1999;67:1887-1890.[Abstract/Free Full Text]
19. 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]
20. Jacobs MJ, deMol BA, Veldman DJ. Aortic arch and proximal supraaortic arterial repair under continuous antegrade cerebral perfusion and moderate hypothermia Cardiovasc Surg 2001;9:396-402.[Medline]
21. Di Eusanio M, Schepens MA, Kazui T, et al. Brain protection using antegrade selective cerebral perfusion: a multicenter study Ann Thorac Surg 2003;76:1181-1189.[Abstract/Free Full Text]
22. Spielvogel D, Halstead JC, Griepp RB, et al. Aortic arch replacement using a trifurcated graft: simple, versatile, and safe Ann Thorac Surg 2005;80:90-95.[Abstract/Free Full Text]
23. Kouchoukos NT, Masetti P. Total aortic arch replacement with a branched graft and limited circulatory arrest of the brain J Thorac Cardiovasc Surg 2005;129:1207-1208.[Free Full Text]

This article has been cited by other articles:

				WRITING COMMITTEE MEMBERS, L. F. Hiratzka, G. L. Bakris, J. A. Beckman, R. M. Bersin, V. F. Carr, D. E. Casey Jr, K. A. Eagle, L. K. Hermann, E. M. Isselbacher, et al. Special Article: 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients with Thoracic Aortic Disease: Executive Summary: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine Anesth. Analg., August 1, 2010; 111(2): 279 - 315. [Full Text] [PDF]

				American College of Cardiology Foundation, American Heart Association Task Force on Practice, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interve, Society of Interventional Radiology, Society of Thoracic Surgeons, Society for Vascular Medicine, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease J. Am. Coll. Cardiol., April 6, 2010; 55(14): e27 - e129. [Full Text] [PDF]

				American College of Cardiology Foundation, American Heart Association Task Force on Practice, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interve, Society of Interventional Radiology, Society of Thoracic Surgeons, Society for Vascular Medicine, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease: Executive Summary J. Am. Coll. Cardiol., April 6, 2010; 55(14): 1509 - 1544. [Full Text] [PDF]

				WRITING GROUP MEMBERS, L. F. Hiratzka, G. L. Bakris, J. A. Beckman, R. M. Bersin, V. F. Carr, D. E. Casey Jr, K. A. Eagle, L. K. Hermann, E. M. Isselbacher, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine Circulation, April 6, 2010; 121(13): e266 - e369. [Full Text] [PDF]

				WRITING COMMITTEE MEMBERS, L. F. Hiratzka, G. L. Bakris, J. A. Beckman, R. M. Bersin, V. F. Carr, D. E. Casey Jr, K. A. Eagle, L. K. Hermann, E. M. Isselbacher, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease: Executive Summary: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine Circulation, April 6, 2010; 121(13): 1544 - 1579. [Full Text] [PDF]

				D. L. Reich Central Nervous System Protection in Cardiac Surgery Seminars in Cardiothoracic and Vascular Anesthesia, March 1, 2010; 14(1): 32 - 37. [Abstract] [PDF]

				H. Takayama, C. R. Smith, M. E. Bowdish, and A. S. Stewart Open distal anastomosis in aortic root replacement using axillary cannulation and moderate hypothermia. J. Thorac. Cardiovasc. Surg., June 1, 2009; 137(6): 1450 - 1453. [Abstract] [Full Text] [PDF]

				Y. Miyamoto, S. Fukui, T. Kajiyama, M. Mitsuno, M. Yamamura, H. Tanaka, M. Ryomoto, and H. Nishi Analysis of collateral blood flow to the lower body during selective cerebral perfusion: is three-vessel perfusion better than two-vessel perfusion? Eur J Cardiothorac Surg, April 1, 2009; 35(4): 684 - 688. [Abstract] [Full Text] [PDF]

				P. G. Malvindi, G. Scrascia, and N. Vitale Is unilateral antegrade cerebral perfusion equivalent to bilateral cerebral perfusion for patients undergoing aortic arch surgery? Interact CardioVasc Thorac Surg, October 1, 2008; 7(5): 891 - 897. [Abstract] [Full Text] [PDF]

				T. M. Sundt III, T. A. Orszulak, D. J. Cook, and H. V. Schaff Improving Results of Open Arch Replacement Ann. Thorac. Surg., September 1, 2008; 86(3): 787 - 796. [Abstract] [Full Text] [PDF]

				H. Watanuki, H. Ogino, K. Minatoya, H. Matsuda, H. Sasaki, M. Ando, and S. Kitamura Is Emergency Total Arch Replacement With a Modified Elephant Trunk Technique Justified for Acute Type A Aortic Dissection? Ann. Thorac. Surg., November 1, 2007; 84(5): 1585 - 1591. [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): Hitoshi Ogino Hitoshi Matsuda Kenji Minatoya Motomi Ando Soichiro Kitamura Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Sasaki, H. Articles by Kitamura, S. Search for Related Content PubMed PubMed Citation Articles by Sasaki, H. Articles by Kitamura, S. Related Collections Great vessels