Technique and rationale for branch-first total aortic arch repair

Abstract

Objective: Our objective was to describe the technique and rationale for branch-first total aortic arch repair.

Methods: Branch-first total aortic arch repair involves serial clamping, reconstruction, and reperfusion of each of the arch branches using a specially designed trifurcation graft with a side port. During this sequence, perfusion to the heart and distal organs are preserved and continuous antegrade cerebral perfusion is permitted via the trifurcation graft. The diseased aorta is excised and replaced with a Dacron graft (W.L. Gore and Associates, Newark, Del) with a perfusion side port. The trifurcation graft is anastomosed to the new proximal ascending aorta.

Results: The branch-first technique permits total aortic arch repair without global cerebral circulatory arrest and excessive hypothermia. It shortens distal organ and cardiac ischemic time, and reduces the opportunity for air and particulate embolization during aortic repair.

Conclusions: Branch-first total aortic arch repair allows continuous antegrade cerebral perfusion and shortens distal organ and cardiac ischemic time, with unobstructed access to the full extent of the diseased aortic arch.

Keywords: IA, innominate artery; LCCA, left common carotid artery; LSCA, left subclavian artery; TAPP, trifurcation arch graft with side perfusion port; antegrade cerebral perfusion; aortic arch replacement; branch-first; total aortic arch repair.

Branch-first total arch repair using continuous antegrade cerebral perfusion.

Figure 1

The innominate artery (IA) is clamped just proximal to its bifurcation and then just distal to its origin from the arch and divided. The distal IA stump is anastomosed to the first limb of the trifurcation graft with 5/0 Prolene suture. Thorough de-airing maneuvers are performed and then the clamps are rearranged to resume antegrade perfusion to the IA via a separate head circuit, which attaches to the side port of the trifurcation arch graft with side perfusion port (TAPP) graft. The IA proximal stump is often conveniently rapidly ligated with a silk suture. The very proximal position of the IA clamp allows the rich collateral networks around the head and neck to augment right hemispheric perfusion over and beyond that provided by the circle of Willis.

Figure 2

With the debranched innominate (IA) out of the field, there is further improvement in exposure to the left common carotid artery (LCCA). The LCCA is mobilized, divided between 2 clamps, and anastomosed to the second limb of the trifurcation graft with 5/0 Prolene suture. Throughout this time, antegrade cerebral perfusion continues via the side port of the trifurcation arch graft with side perfusion port (TAPP) graft. Thorough de-airing maneuvers are performed and then the clamps are again rearranged to resume antegrade perfusion to both the IA and LCCA.

Figure 3

The descending aorta is controlled either with a clamp, endoluminal balloon or distal circulatory arrest, depending on pathology treated and local condition. Myocardial protection is initiated and maintained by antegrade and retrograde cardioplegia. Visceral and spinal cord perfusion is maintained via femoral arterial inflow. Antegrade cerebral perfusion continues via the side port of the trifurcation arch graft with side perfusion port (TAPP) graft to the attached head vessels. The arch is excised and the distal aortic anastomosis is performed using a tube graft with a pre-attached side port for subsequent antegrade distal perfusion. De-airing maneuvers are performed and the aortic clamp is repositioned on the tube graft proximal to the side port allowing distal re-perfusion to be swapped from femoral retrograde to antegrade.

Figure 4

The common stem of the trifurcation arch graft with side perfusion port (TAPP) graft is passed under the innominate vein and anastomosed to a hole in the tube graft corresponding to the new ascending aorta. Cerebral perfusion is maintained throughout this period as the side port of the TAPP graft is conveniently located close to the innominate (IA) branch. This anastomosis can be delayed until after the proximal aortic anastomosis to further reduce myocardial ischemia time.