title: Use of carotid-subclavian arterial bypass and thoracic endovascular aortic repair to minimize cerebral ischemia in total aortic arch reconstruction.
abstract: OBJECTIVE
  Total aortic arch replacement typically requires hypothermic circulatory arrest, carrying risks of cerebral ischemia. We recently introduced left carotid-subclavian bypass before total aortic arch replacement with thoracic stent grafting to achieve hybrid arch reconstruction with short periods of selective antegrade cerebral perfusion.
  
  
  METHODS
  From 2004 to 2009, 332 patients underwent ascending aorta or arch replacements. Of these, 37 underwent total aortic arch replacement. In 2008, we began performing left carotid-subclavian bypass before subtotal arch replacement, with side-graft anastomoses to innominate and left carotid arteries. Patients then underwent aortic graft stent deployment to complete arch reconstruction. Twenty-eight patients underwent conventional arch replacement (group I); 9 underwent hybrid arch replacement (group II).
  
  
  RESULTS
  Selective antegrade cerebral perfusion time in group I was 33.3 +/- 13.7 minutes versus 18.9 +/- 9.2 minutes in group II (P = .007). Among group I patients, 82% required hypothermic circulatory arrest (vs 0% in group II, P < .001). Mean cardiopulmonary bypass and aortic crossclamp times were longer in group I than group II (P < .05). Incidence of neurologic complications was 14% in group I (4/28) versus 0% (0/9) in group II, although this finding did not reach statistical significance (P = .55).
  
  
  CONCLUSIONS
  Left carotid-subclavian bypass before arch replacement with staged thoracic stent grafting to achieve hybrid arch reconstruction was associated with decreased selective antegrade cerebral perfusion, cardiopulmonary bypass, and aortic crossclamp times and eliminated hypothermic circulatory arrest. This technique may minimize neurologic complications associated with arch replacement and provide a viable hybrid approach to patients with arch aneurysms and dissections.
authors.affiliation: Gagnon Cardiovascular Institute, Department of Cardiovascular Medicine, Morristown Memorial Hospital, Morristown, 100 Madison Ave, Morristown, NJ 07960, USA. steve.xydas@atlantichealth.org
authors.forename: Steve
authors.initials: S
authors.lastname: Xydas
authors.forename: Benjamin
authors.initials: B
authors.lastname: Wei
authors.forename: Hiroo
authors.initials: H
authors.lastname: Takayama
authors.forename: Mark
authors.initials: M
authors.lastname: Russo
authors.forename: Matthew
authors.initials: M
authors.lastname: Bacchetta
authors.forename: Craig R
authors.initials: CR
authors.lastname: Smith
authors.forename: Allan
authors.initials: A
authors.lastname: Stewart
mesh_terms: D001013:Aorta, Thoracic / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000601:surgery*; D002545:Brain Ischemia / Q000517:prevention & control*; D002339:Carotid Arteries / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011474:Prosthesis Design; D012189:Retrospective Studies; D015607:Stents; D013348:Subclavian Artery / Q000601:surgery*