Surgical Technique
All cases are operated under general anesthesia after invasive arterial
pressure monitoring of bilateral radial arteries and a femoral artery.
We cannulate the right jugular vein after oro-tracheal intubation and
position a Swan-Ganz catheter. All patients are monitored with a
continuous transesophageal echocardiography (TEE) and bilateral cerebral
oxymetry (INVOSTM system). Median sternotomy is
performed in all cases: the usual incision is extended in a small right
or bilateral supra-clavicular cervicotomy to improve access and
harvesting of supra-aortic vessels. Central cannulation is routinely via
the right intrathoracic subclavian artery via side graft . Our approach
is “branch-first” and beating heart arch vessel reconstruction. During
the initial cooling phase, on a beating heart, the left carotid artery
(LCA) and the left subclavian artery (LSA) are isolated and prepared for
selective cannulation with the interposition of a 8—10 mm Dacron graft
(respectively for LCA and LSA) to avoid direct cannulation of the artery
(Figure 1). The vessel perfusion is sequentially started to achieve
complete antegrade cerebral perfusion. Bladder and esophageal
temperature are monitored. Right atrium and right superior pulmonary
vein are cannulated for venous return and venting.
After debranching completion at 30°C core temperature, the aorta is
cross-clamped and opened and a single dose of Custodiol® cardioplegia is
administered for cardiac protection. Proximal aortic reconstruction
varies according to underlying pathology. Patients are cooled to 26°C
for hypothermic circulatory arrest and the brachiocephalic artery
clamped and selective antegrade perfusion begun at 10—12 mL/kg/min,
consequently stopping systemic circulation. INVOS is monitored and
radial pressure maintained at 60—80 mmHg. The aortic arch is then
opened and inspected.
The landing zone (usually zone 2) is reinforced with Teflon strip and,
eventually, bioglue. At this stage, the distal stent-graft of the FET
device is released into the descending thoracic aorta. The reinforced
collar of the prosthesis is sutured to the aortic isthmus and, after
cannulation of the fourth lateral branch and careful de-airing, systemic
perfusion resumed, starting to rewarm the body. The anastomosis between
the surgical graft and sinotubular junction (either native or
prosthetic, depending on the proximal repair) is completed and
cross-clamp released. The prosthesis-elongated supra-aortic vessels are
then end-to-end sequentially re-anastomosed to the corresponding
branches of the graft, starting with the LSA to LCA and finally
brachiocephalic artery. The correct deployment and fully expansion of
the prosthesis is assessed by TEE.