title: Trifurcated graft replacement of the aortic arch: state of the art.
abstract: OBJECTIVE
  To review the contemporary practice in total arch replacement (TAR) by using the trifurcated graft technique.
  
  
  METHODS
  The evolution of the trifurcated graft technique in total arch replacement is described. Axillary artery perfusion with antegrade cerebral perfusion (ACP) is routinely performed, with systemic deep hypothermia based on the anticipated interval of lower body ischemia. Cerebral oxygen saturation is monitored and bilateral ACP (BACP) is performed if the adequacy of collateral circulation is questioned. Potential advantages and disadvantages of unilateral ACP (UACP) vs BACP are discussed.
  
  
  RESULTS
  The advantage of the trifurcated graft technique in TAR is that it facilitates the creation of an "elephant trunk" in the proximal arch, making the operation technically easier and avoiding the risk of recurrent laryngeal nerve injury. The technique is also versatile in a variety of aortic arch anatomies and pathologies, while enabling continuous ACP without hypothermic circulatory arrest for cerebral protection. UACP during TAR is acceptable for shorter intervals (<30-40 minutes) if combined with moderate hypothermia. BACP should be considered for prolonged ACP interval or if left cerebral oxygenation is inadequate during UACP.
  
  
  CONCLUSIONS
  The trifurcated graft technique is a versatile method in TAR that can be applied to a diverse range of aortic anatomies, pathologies and hybrid arch procedures, with concomitant or staged endovascular options. UACP or BACP and lower body ischemia can be performed without adding significant complexity to the procedure, while conferring maximal cerebral, spinal, and lower body protection.
authors.affiliation: Section of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY.
authors.forename: Gilbert H L
authors.initials: GH
authors.lastname: Tang
authors.affiliation: Section of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY.
authors.forename: Masashi
authors.initials: M
authors.lastname: Kai
authors.affiliation: Section of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY.
authors.forename: Ramin
authors.initials: R
authors.lastname: Malekan
authors.affiliation: Section of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY.
authors.forename: Steven L
authors.initials: SL
authors.lastname: Lansman
authors.affiliation: Section of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY. Electronic address: SpielvogelD@WCMC.com.
authors.forename: David
authors.initials: D
authors.lastname: Spielvogel
mesh_terms: D001013:Aorta, Thoracic / Q000503:physiopathology / Q000601:surgery*; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation*; D002560:Cerebrovascular Circulation; D050792:Circulatory Arrest, Deep Hypothermia Induced; D003097:Collateral Circulation; D006439:Hemodynamics; D006801:Humans; D010477:Perfusion; D011474:Prosthesis Design; D016896:Treatment Outcome