title: Congenital anomalies of the aortic arch in acute type-a aortic dissection: implications for monitoring, perfusion strategy, and surgical repair.
abstract: OBJECTIVE
  To assess whether management of acute Stanford type-A aortic dissection differs in patients with congenital anomalies of the aortic arch compared with standard institutional practice.
  
  
  METHODS
  Retrospective analysis of all consecutive patients from 2001 through 2011.
  
  
  METHODS
  Quaternary referral center for surgical management of thoracic aortic disease.
  
  
  METHODS
  All patients with arch anomalies who underwent surgery for acute Stanford type-A aortic dissection during the study period (n = 43).
  
  
  METHODS
  Surgical management, anesthetic monitoring, and perfusion strategy were analyzed in a retrospective fashion. No new interventions were undertaken as part of this study.
  
  
  RESULTS
  Management differed most in patients with an aberrant right subclavian artery (n = 5), because the institutional standard of right axillary artery cannulation with left upper extremity arterial pressure monitoring was not possible. In patients with one of two "bovine" arch patterns (n = 32), management differed in the conduct of selective antegrade cerebral perfusion, which could include clamping above or below the takeoff of the left common carotid artery (and, therefore, produced unilateral or bilateral antegrade cerebral perfusion). All patients with a connective tissue disorder exhibited a bovine arch pattern. Management of patients with a right arch (n = 3) reflected the opposite of management for normal anatomy (for patients with traditional mirror-image branching) or opposite that of the aberrant right subclavian group (for patients who had a corresponding aberrant left subclavian artery).
  
  
  CONCLUSIONS
  Rational management reflected the anatomic variations observed. These results support the importance of interdisciplinary planning, especially in an emergency, to optimize outcome.
authors.affiliation: Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. Electronic address: bmaxwell@jhu.edu.
authors.forename: Bryan G
authors.initials: BG
authors.lastname: Maxwell
authors.affiliation: Department of Cardiothoracic Surgery, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA.
authors.forename: Katherine B
authors.initials: KB
authors.lastname: Harrington
authors.affiliation: Department of Cardiothoracic Surgery, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA.
authors.forename: Ramin E
authors.initials: RE
authors.lastname: Beygui
authors.affiliation: Departments of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA.
authors.forename: Daryl A
authors.initials: DA
authors.lastname: Oakes
mesh_terms: D000328:Adult; D000368:Aged; D000784:Aortic Dissection / Q000145:classification / Q000473:pathology* / Q000601:surgery*; D001013:Aorta, Thoracic / Q000002:abnormalities*; D017545:Aortic Aneurysm, Thoracic / Q000145:classification / Q000473:pathology* / Q000601:surgery*; D062186:Arterial Pressure / Q000502:physiology; D015331:Cohort Studies; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative; D010477:Perfusion; D012189:Retrospective Studies; D014656:Vascular Surgical Procedures / Q000379:methods*; D055815:Young Adult
keywords: abnormal aortic arch; acute aortic dissection; aortic arch anomalies; cannulation strategy; perfusion strategy; type-A aortic dissection