title: Optimization of aortic arch replacement with a one-stage approach.
abstract: BACKGROUND
  Staged procedures for extensive aneurysmal disease of the thoracic aorta are associated with a substantial cumulative mortality for the two procedures and death in the interval between, often from aortic rupture. We have used a one-stage approach for operative repair of most, or all, of the thoracic aorta.
  
  
  METHODS
  Sixty-nine patients were treated using a bilateral anterior thoracotomy with transverse sternotomy, hypothermic circulatory arrest, and reperfusion of the arch vessels first to minimize brain ischemia. Forty-two patients had chronic ascending aortic dissections (all but 1 had a previous operation), 24 had degenerative aneurysms, and 3 had chronic descending aortic dissections with proximal extension. The ascending aorta and aortic arch were replaced in all patients combined with resection of various lengths of descending aorta.
  
  
  RESULTS
  In-hospital mortality was 7.2% (5 patients). Morbidity included reoperation for bleeding (13%), mechanical ventilation for more than 72 hours (50%), temporary tracheostomy (13%), and temporary renal dialysis (9%). No patient sustained a stroke. There have been 9 late deaths unrelated to the aortic disease. Four patients have undergone successful reoperation on the aorta for false aneurysm in 1, endocarditis in 1, and progression of disease in 2. Survival at 5 years was 71%.
  
  
  CONCLUSIONS
  The one-stage arch-first technique is a safe and suitable alternative to the two-stage procedure for repair of extensive thoracic aortic disease.
authors.affiliation: Division of Cardiovascular and Thoracic Surgery, Missouri Baptist Medical Center, St. Louis, Missouri, USA. ntkouch@aol.com
authors.forename: Nicholas T
authors.initials: NT
authors.lastname: Kouchoukos
authors.forename: Michael C
authors.initials: MC
authors.lastname: Mauney
authors.forename: Paolo
authors.initials: P
authors.lastname: Masetti
authors.forename: Catherine F
authors.initials: CF
authors.lastname: Castner
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017541:Aneurysm, False / Q000601:surgery; D001013:Aorta, Thoracic / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000379:methods* / Q000401:mortality / Q000592:standards; D018450:Disease Progression; D004696:Endocarditis / Q000601:surgery; D005260:Female; D006353:Heart-Assist Devices; D006470:Hemorrhage / Q000209:etiology / Q000601:surgery; D017052:Hospital Mortality; D006801:Humans; D008171:Lung Diseases / Q000209:etiology / Q000601:surgery; D008297:Male; D008875:Middle Aged; D006435:Renal Dialysis; D051437:Renal Insufficiency / Q000209:etiology / Q000628:therapy; D012086:Reoperation; D012121:Respiration, Artificial; D013927:Thrombosis / Q000209:etiology / Q000601:surgery; D013997:Time Factors; D014139:Tracheostomy; D018497:Ventricular Dysfunction, Right / Q000209:etiology / Q000628:therapy