title: Aortic arch replacement without circulatory arrest or deep hypothermia: the "branch-first" technique.
abstract: OBJECTIVE
  Although current developments in aortic arch replacement have demonstrated progressively improving mortality, cerebral morbidity remains significant. We describe a "branch-first" technique that avoids circulatory arrest and profound hypothermia, yielding excellent survival and low cerebral morbidity.
  
  
  METHODS
  From September 2005 to February 2014, 64 patients underwent the "branch-first" technique for aortic arch replacement. Each arch branch is individually isolated for a brief period while it is anastomosed to a perfused trifurcation graft. The disconnection-reconnection sequence proceeds from the innominate artery to the left subclavian artery, with uninterrupted perfusion of the heart and viscera. After reconstruction of the debranched arch and ascending aorta, the common stem of the trifurcation graft is anastomosed to the arch graft. In this series, there were 39 male patients, and the mean age was 65 (range, 17-85) years. Twenty-five cases (39.1%) were of urgent/emergency status. Thirty-one patients (48.4%) underwent operation for aortic dissection, and the remaining patients underwent operation for aneurysms. Sixteen patients (25.0%) had previously undergone a cardiac surgical procedure.
  
  
  RESULTS
  There were 2 (3.1%) early mortalities, and 1 patient (1.6%) had a permanent stroke. One patient (1.6%) required mechanical support, and 4 patients (6.3%) required hemofiltration for renal support. Ten patients (15.6%) did not require transfusion of red cells or any other blood product.
  
  
  CONCLUSIONS
  The "branch-first" technique described brings us closer to the goal of arch surgery with cerebral, vital organ, and survival outcomes similar to those we expect from ascending aortic and root procedures.
authors.affiliation: Department of Cardiac Surgery, Austin Hospital, University of Melbourne, Melbourne, Australia. Electronic address: george.matalanis@austin.org.au.
authors.forename: George
authors.initials: G
authors.lastname: Matalanis
authors.affiliation: Department of Cardiac Surgery, Austin Hospital, University of Melbourne, Melbourne, Australia.
authors.forename: Nisal K
authors.initials: NK
authors.lastname: Perera
authors.affiliation: Department of Cardiac Surgery, Austin Hospital, University of Melbourne, Melbourne, Australia.
authors.forename: Sean D
authors.initials: SD
authors.lastname: Galvin
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000784:Aortic Dissection / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D001013:Aorta, Thoracic / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods* / Q000401:mortality; D050792:Circulatory Arrest, Deep Hypothermia Induced / Q000009:adverse effects / Q000401:mortality; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010477:Perfusion; D011183:Postoperative Complications / Q000401:mortality / Q000628:therapy; D011474:Prosthesis Design; D016896:Treatment Outcome; D055815:Young Adult