G. Chad Hughes, MD, Mani A. Daneshmand, MD, Keki R

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“Hybrid” Repair of Aneurysms of the Transverse Aortic Arch: Midterm Results G. Chad Hughes, MD, Mani A. Daneshmand, MD, Keki R. Balsara, MD, Hardean A. Achneck, MD, Bantayehu Sileshi, MD, Sean M. Lee, MD, Richard L. McCann, MD The Annals of Thoracic Surgery Volume 88, Issue 6, Pages 1882-1888 (December 2009) DOI: 10.1016/j.athoracsur.2009.07.027 Copyright © 2009 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Aortic landing zone map devised by Ishimaru [7] and location of proximal landing zone (PLZ) for hybrid arch patients in the present series. Eight of 9 patients undergoing adjunctive carotid-carotid bypass had zone 1 PLZ, with the exception being 1 patient status post ascending aorta to right subclavian artery (SCA) bypass at the time of type A dissection repair at another institution; she subsequently underwent right subclavian to right carotid to left carotid artery bypass to create a zone 0 PLZ. All patients undergoing ascending aortic-based arch debranching procedures (n = 12) had zone 0 PLZ, in addition to the single carotid-carotid bypass patient (n = 13 total zone 0 PLZ). Patients (n = 7) undergoing first-stage total arch replacement/elephant trunk had zone 3/4 PLZ in the elephant trunk graft. (Modified from Ishimaru S, J Endovasc Ther 2004;11:II62–71 [7], with permission from Allen Press Publishing Services.) The Annals of Thoracic Surgery 2009 88, 1882-1888DOI: (10.1016/j.athoracsur.2009.07.027) Copyright © 2009 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Intraoperative photograph demonstrating completed concomitant ascending aortic replacement and arch debranching procedure. The arch debranching graft (black arrow) has been anastomosed to the proximal end of the ascending graft, thus creating several centimeters of proximal landing zone (PLZ) in the ascending graft above the takeoff of the debranching graft. The endograft has been deployed within the ascending graft and the proximal antegrade limb of the debranching graft (used for introduction of the endograft and not visible) has been oversewn. The Annals of Thoracic Surgery 2009 88, 1882-1888DOI: (10.1016/j.athoracsur.2009.07.027) Copyright © 2009 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Drawing demonstrating modified Mt. Sinai technique [8] used for first-stage total arch replacement in patients with extensive thoracic aortic disease but adequate distal landing zone (DLZ) in descending aorta. (A) The right axillary artery is cannulated with an 8 mm Dacron graft using a side graft technique. (B) After cooling to electrocerebral inactivity by electroencephalogram, the three arch vessels are divided from their origins at the arch, clamped, and antegrade cerebral perfusion from the right axillary graft begun. (C) A trifurcated graft is then anastomosed to the arch vessels, and full flow to the upper body resumed at 12°C. The collared elephant trunk graft is then anastomosed to the divided arch, after which lower body perfusion is resumed and rewarming begun through a Y in the arterial line and the integral side arm in the elephant trunk graft. The collar allows the elephant trunk anastomosis to be better matched to the diameter of the dilated transverse arch, which decreases tension at this anastomosis [9]. (D) Completed first-stage repair. The Annals of Thoracic Surgery 2009 88, 1882-1888DOI: (10.1016/j.athoracsur.2009.07.027) Copyright © 2009 The Society of Thoracic Surgeons Terms and Conditions