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.