separated graft technique 29 II HCA SCP continuous cold blood cardioplegia P<0.05 I cerebrovascular accident CVA II CVA

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1 Bentall en bloc technique14 I 1997 separated graft technique29 II HCA SCP continuous cold blood cardioplegia CCBC HCA I II SCP I II I P<0.05 I cerebrovascular accident CVA II P<0.05 I II CVA I P< I CVA 1997HCA SCPCCBC aorta non-touch technique open proximal and distal anastomosis CVA Tel:

2 12 3 Fig. 1 The perfusion circuit of the brian and the coronary arteries with cold blood. Ox; oxigenator, P 1; centrifugal pump, P 2; roller pump, CS; coronary sinus, RA; right artium, FA; femoral artery, RAxA; right axiallary artery, RBA; right brachiocephalic artery, LCA; left carotid artery, LSA; left subclavian artery Stanford A 29 Stanford A Stanford B Bentall 4 1 Fig C hypothermic circulatory arrest HCA ml selective cerebral perfusion SCP ml/min mmHg HCA Young 2 ml / kg GIK20 l / kg 20 continuous cold blood cardioplegia CCBC 2 HCA open distal anastomosis Teflon felt gelatine resorcin formaldehyde glue GRF glue Fig. 2: A cm Teflon feltmodified elephant trunk technique Fig. 2: B intimal flapdouble barrel Fig. 2: C en block en bloc technique Fig. 3: A 14 I Woven Dacron 3 separated graft technique Fig. 3: B 29 II 3 32 C 35 C Mean SD Chi-square test unpaired Student t - test 2

3 2003 (A) (B) (C) Fig. 2 Schematic illustration of the distal anastomosis portion. (A) The distal aorta repair was carried out using interrupted suture with reinforcement of a Teflon felt strip. (B) The elephant trunk prosthesis was inserted in to the descending aorta and interrupted suture with reinforcement of Teflon felt strip from the outside of anastomosis was performed. The separated graft was anastomosed out using over and over suture to distal prosthesis. (C) The intimal flap was extirpated from the distal aorta and the distal aorta with reinforcement of Teflon felt strip was anastomosed by end to end fashion to the prosthesis. TL; true lumen, FL; false lumen 5% eventmean SE Kaplan-Meier Logrank test total pump time I II cardiac ischemic time I II circulatory arrest time I II selective cerebral perfusion time I II I (P<0.05) Bentall I 1 II 2 1 II 2 II Table 1 I II I 1 MOF 3 3

4 12 3 (A) (B) Fig. 3 Schematic illustration of the aortic arch reconstruction. (A) En bloc technique: Under the brain perfusion, the vascular prosthesis was anastomosed to the distal aorta. Arch vessels were extirpated in island fashion and the anastomosis was carried out using running suture. (B) Separated graft technique: Arch vessels were reconstructed by end to end anastomosis to the side branches of the prosthesis. debris II 1 MNMS CABG MOF I II % en bloc technique I II P< I 1 10 II I 2 II Fig I II low risk Fig. 5 Table 1 Summary of postoperative complications = < Marfann SCP HCA CCBC SCP 1 30 C 20 C 40 4

5 2003 Fig. 4 Survival for the patients undergoing total arch replacement. Fig. 5 Freedom from reoperation after total arch replacement. 2 5 SCP SCP 20 HCA HCA debris SCP debris Thin-Wall 5

6 12 3 Table 2 Comparison with early mortality < Dispersion TM cannula CCBC 180 HCA open distal anastomosis Teflon felt 2 GRF glue cmTeflon felt modified elephant trunk technique intimal flap double barrel 22 reentry open distal anastomosis separated technique inclusion technique en bloc technique separated graft technique en bloc technique I cerebrovascular accident CVA separated graft technique II debris en bloc technique separated graft technique CVA 216 CVA low risk HCA SCP CCBC aora non-touch open proximal and distal anastomosis 4 6

7 ?? Svensson, L. G., Crawford, E. S., Hess, K. R., et al.: Deep hypothermia circulatory arrest; determinants of stroke and early mortality in 656 patients. J. Thorac. Cardiovasc. Surg., 106: 19-31, Ergin, M. A., Galla, J. D., Lansman, S. L., et al.: Hypothermic circulatory arrest in operation on thoracic aorta; determinants of operative mortality and neurologic outcome. J. Thorac. Cardiovasc. Surg., 107: , Coselli J. S., Buket, S. and Djukanovic, B.: Aortic arch operation; current treatment and results. Ann. Thorac. Surg., 59: 19-27, Bachet, J., Guilment, D., Goudot, B., et al.: Antegrade cerebral perfusion with cold blood; a 13-year experience. Ann. Thorac. Surg., 67: , Kazui, T., Washiyama, N., Bashar, A. H. M., et al.: Improved results of atherosclerotic arch aneurysm operation with a refined technique. J. Thorac. Cardiovasc. Surg., 121: , Hagl, C., Ergin, M. A., Galla, J. D., et al.: Neurologic outcome after ascending aota-aoric arch operations; effect of brain protection technique in high-risk patients. J. Thorac. Cardiovasc. Surg., 121: , Ehrlich, M. P., Hagl, C., McCullough, J. N., et al.: Retrograde cerebral perfusion provides negligible flow through brain capillaries in the pig. J. Thorac. Cardiovasc. Surg., 122: , LeMaire, S. A., Bhama, J. K., Schmittling, Z. C., et al.: S- 100 correlates with nurologic complications after aortic operation using circulatory arrest. Ann. Thorac. Surg., 71: , Deeb, G. M., Jenkins, E., Bolling, S. F., et al.: Retrograde cerebral perfusion during hypothermic circulatory arrest reduces neurologic morbidity. J. Thorac. Cardiovasc. Surg., 109: , Crawford, E. S., Saleh, S. A. and Schuessler, J. S.: Treatment of aneurysm of transverse aortic arch. J. Thorac. Cardiovasc. Surg., 78: , Ergin, M. A., O'Connor, J., Guinto, R., et al.: Experience with profound hypothermia and circulatory arrest in the treatment of aneurysm of the aortic arch; aortic arch replacement for acute arch dissection. J. Thorac. Cardiovasc. Surg., 84: , Susaguri, S., Yamamoto, S., Fukuda, T., et al.: Anteroaxillary thoracotomy facilitates the use of retrograde cerebral perfusion in distal aortic arch reconstruction. Ann. Throrac.Surg., 62: , Okita, Y., Ando, M., Minatoya, K., et al.: Predictive factors for mortality and cerebral complications in arteriosclerotic aneurysm of the aortic arch. Ann. Thorac. Surg., 67: 72-78, Miller, D. C., Stinson, E. B., Oyer, P. E., et al.: Operative treatment of aortic dissections. Experience with 125 patients over a sixteen-year period. J. Thorac. Cardiovasc. Surg., 78: , Bachet, J., Goudot, B., Dreyfus, G., et al.: The proper use of glue; a 20-year experience with the GRF glue in acute aortic dissection. J. Card. Surg., 12: , Bachet J. and Guilmet D.: The use of biological glue in aortic surgery. Cardiol. Clin., 17: , Kazui, T., Washiyama, N., Bashar, A. H. M., et al.: Role of biologic glue repair of proximal aortic dissection in the development of early and midterm redissection of the aortic root. Ann. Thorac. Surg., 72: , Massimo, C. G., Presenti, L. F., Marranci, P., et al.: Extended and total aortic resection in the surgical treatment of acute type A aortic dissection: experience with 54 patients. Ann. Thorac. Surg., 46: , Massimo, C. G., Presenti, L. F., Favi, P. P., et al.: Excision of the aortic wall in the surgical treatment of acute type-a aortic dissection. Ann. Thorac. Surg., 50: , Lansman, S. L., Raissi, S., Ergin, M. A., et al.: Urgent operation for acute transverse aortic arch dissection. J. Thorac. Cardiovasc. Surg., 97: , Kazui, T., Washiyama, N., Muhammad, B. A. H., et al.: Total arch replacement using arch branched grafts with the aid of antegrade selective cerebral perfusion. Ann. Thorac. Surg., 70: 3-9,

8 Kuki, S., Taniguchi, K., Masai, T., et al.: A novel modification of elephant trunk technique using a four-branched arch graft for extensive thoracic aortic aneurysm. Eur. J. Cardiothorac. Surg., 18: , Bednarkiewicz, M., Khatchatourian, G., Christenson, J. T., et al.: Aortic arch replacement using a four-branched aortic arch graft. Eur. J. Cardiothorac. Surg., 21: 89-91, Surgical Strategies for Aortic Arch Replacement Using a Separated Prosthetic Graft Shigeru Sakamoto, Junichi Matsubara, Toshiaki Matsubara, Yasuhiro Nagayoshi, Hisateru Nishizawa, Sinji Shono, Masaaki Kanno, Katsunori Takeuchi, Toshimichi Nonaka and Jun Kiyosawa Department of Thoracic and Cardiovascular Surgery, Kanazawa Medical University, Ishikawa, Japan Key words: Total aortic arch replacement, Selective cerebral perfusion, Hypothermic circulatory arrest, Separated prosthetic graft, Cerebrovascular accident Purpose: The aim of this study was to evaluate the operative techniques of total arch replacement and the surgical results. Method: Until February 2003, total aortic arch replacement was performed in 43 patients. There were 26 men and 17 women, and the age ranged from 35 to 81 years with a mean age of 62 years. The operative technique for arch replacement used separated prosthetic grafts, selective cerebral perfusion (SCP), continuous cold blood cardioplegia (CCBC), and open distal anastomosis under hypothermic circulatory arrest (HCA). Combined procedures consisted of coronary bypass grafting, in 4 patients, aortic valve resuspension, in 2 patients, and Bentall s procedure, in 4 patients. Results: The hospital mortality rate was 20.9% (9 of the 43 patients). The causes of death were cerebral infarction in 3 patients, multiple organ failure due to renal and intestinal ischemia and massive bleeding in 2, pulmonary embolism in 1, pneumonia in 1, mediastinitis in 1, and myonephropathic metabolic syndrome in 1, respectively. The long-term results yielded an actuarial survival rate of 66.9% for 10 years. The percentage of cases free of reoperation was 76.9% for 10 years. Conclusion: The technique of total arch replacement using separated prosthetic grafts, SCP, CCBC, and open distal anastomosis under HCA is a useful operative method in patients with aortic arch aneurysm and decreases cerebrovascular accidents. Jpn. J. Vasc. Surg., 12: ,