Total Arch Replacement With Frozen Elephant Trunk and Extra-Anatomical Left Subclavian Artery Bypass

A bilateral axillary cannulation was performed using 10 mm Gelweave grafts. Following a standard median sternotomy, cardiopulmonary bypass was established between the axillary cannulae and a dual-stage venous cannula in the right atrium. A double Y configuration was used for the arterial line of the bypass circuit, splitting the arterial line into three separate lines. A left ventricular vent was placed via the right superior pulmonary vein. Cooling commenced, with a target temperature of 26 degrees Celsius. Aortic arch vessels were mobilized and encircled with tapes. The aorta was cross-clamped, and the heart was arrested with direct ostial cardioplegia. Proximal aortic repair was performed by resuspending the commissures and reapproximating the dissected layers of the aorta with biological glue. Once the patient was cooled to 26 Celsius, the systemic circulation was arrested, the patient was drained, the aortic cross-clamp was removed, and selective antegrade cerebral perfusion commenced with the innominate artery clamped. The left carotid artery was also subsequently clamped. The arch vessels, including the innominate and left carotid arteries, were debranched, and the left subclavian artery was ligated. The arch was trimmed and prepared for graft deployment. Three pledgeted sutures were placed 120 degrees apart to maintain graft orientation after deployment. The Thoraflex Hybrid graft was deployed, and the distal anastomosis was performed with a running 4-0 Prolene suture. Once the distal anastomosis was complete, systemic circulation was reestablished through a side perfusion branch of the Thoraflex graft. The head vessel branches, and the open end of the graft were clamped after adequate deairing. The left carotid anastomosis was then performed, followed by the proximal graft-to-aorta anastomosis. The cross-clamp was then removed, and the heart was reperfused. The innominate artery anastomosis was then performed, followed by an extra-anatomical left subclavian artery bypass. The latter was performed by dividing and tunneling the left axillary graft into the mediastinum via the second intercostal space. 

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