title: Left subclavian artery rerouting and selective perfusion management in frozen elephant trunk surgery.
abstract: BACKGROUND
  The frozen elephant trunk (FET) technique enables combined aortic arch and descending aortic repair. We report our experience with a modified arch replacement technique by rerouting of the left subclavian artery (LSA) and fixation of the FET in Zone 2 or proximally under selective perfusion of all three arch arteries and the downstream aorta.
  
  
  METHODS
  From January 2005 to December 2014, 78 of 173 patients operated with the FET technique underwent rerouting of the LSA. Rerouting was performed as aortic-subclavian, aorto-axillary or carotid-subclavia bypass. Hypothermic selective antegrade cerebral perfusion was established for cerebral protection. A separate cardiopulmonary bypass circuit was added for selective LSA and downstream aorta perfusion during the arch repair.
  
  
  RESULTS
  In-hospital mortality, stroke and paraplegia rates were 10%, 8% and 2.5%, respectively. LSA rerouting enabled total arch repair in <60 minutes of selective cerebral perfusion (mean 56 ± 15). No recurrent nerve palsy occurred. The selective perfusion of the downstream aorta led to the reduction of the distal hypothermic circulatory arrest time close to 30 minutes (p < 0.0001).
  
  
  CONCLUSIONS
  LSA rerouting facilitates arch aortic repair by FET surgery. The selective perfusion of all arch arteries and the downstream aorta during open arch repair reduces the ischemic times and may improve organ protection.
authors.affiliation: a Department of Thoracic and Cardiovascular Surgery, West-German Heart Center Essen, University Hospital Essen , Essen, Germany.
authors.forename: Konstantinos
authors.initials: K
authors.lastname: Tsagakis
authors.affiliation: a Department of Thoracic and Cardiovascular Surgery, West-German Heart Center Essen, University Hospital Essen , Essen, Germany.
authors.forename: Daniel Sebastian
authors.initials: DS
authors.lastname: Dohle
authors.affiliation: a Department of Thoracic and Cardiovascular Surgery, West-German Heart Center Essen, University Hospital Essen , Essen, Germany.
authors.forename: Daniel
authors.initials: D
authors.lastname: Wendt
authors.affiliation: a Department of Thoracic and Cardiovascular Surgery, West-German Heart Center Essen, University Hospital Essen , Essen, Germany.
authors.forename: Wolf
authors.initials: W
authors.lastname: Wiese
authors.affiliation: a Department of Thoracic and Cardiovascular Surgery, West-German Heart Center Essen, University Hospital Essen , Essen, Germany.
authors.forename: Jaroslav
authors.initials: J
authors.lastname: Benedik
authors.affiliation: a Department of Thoracic and Cardiovascular Surgery, West-German Heart Center Essen, University Hospital Essen , Essen, Germany.
authors.forename: Helmut
authors.initials: H
authors.lastname: Lieder
authors.affiliation: a Department of Thoracic and Cardiovascular Surgery, West-German Heart Center Essen, University Hospital Essen , Essen, Germany.
authors.forename: Matthias
authors.initials: M
authors.lastname: Thielmann
authors.affiliation: a Department of Thoracic and Cardiovascular Surgery, West-German Heart Center Essen, University Hospital Essen , Essen, Germany.
authors.forename: Heinz
authors.initials: H
authors.lastname: Jakob
mesh_terms: D000368:Aged; D001013:Aorta, Thoracic / Q000601:surgery*; D002315:Cardiopulmonary Bypass; D057510:Endovascular Procedures / Q000009:adverse effects / Q000379:methods*; D005260:Female; D006801:Humans; D007036:Hypothermia, Induced; D008297:Male; D008875:Middle Aged; D061646:Operative Time; D011183:Postoperative Complications / Q000453:epidemiology; D013348:Subclavian Artery / Q000601:surgery*
keywords: Thoracic aortic disease; aortic arch surgery; cardiopulmonary bypass; circulatory arrest; debranching