Interventional treatment for acute cerebral infarction with large vessel occlusion combined with aortic arch interruption: A case report

Rationale:Aortic arch interruption is a type of congenital vascular malformation that is often observed in childhood. Most children die of congestive heart failure due to rapid deterioration. Children can only survive to adulthood if they have extremely rich collateral circulation. Cases of acute cerebral infarction with large vessel occlusion receiving interventional treatment in adult patients with interrupted aortic arch have not been reported.Patient concerns:A 55-year-old man with a history of atrial fibrillation and smoking but without a family history of stroke was admitted to our hospital with a 5-hour history of left limb weakness and speech difficulties.Diagnoses:Emergency brain computed tomography showed a large cerebral infarction in the right frontal temporal parietal lobe. He was suspected to have aortic arch interruption in the early stage of endovascular interventional therapy through the femoral artery approach, and was converted to the transradial artery pathway. The aortic arch was disconnected, and the right internal carotid artery was occluded.Interventions:Considering the possibility of cardiogenic embolism, a middle catheter was used for thrombus aspiration of the right internal carotid artery. After removal of the dark red thrombus was removed, the right internal carotid artery was successfully recanalized.Outcomes:The patient recovered well after the operation. However, the patient and his family refused further treatment for aortic arch interruption. The modified Rankin Scale score was 0 at 3 months and 1 year of follow-up which meant that he recovered quite well.Lessons:Adult patients with acute cerebral infarction with large vessel occlusion are rarely complicated with aortic arch interruption, and emergency thrombectomy via the radial artery approach is feasible.     

Diagnostic Role of Magnetic Resonance Imaging in Identifying Aortic Arch Anomalies

Purpose. The aim of this article was to assess the role of MRI in the diagnosis and management of a variety of complex aortic arch anomalies. Materials and Methods. Imaging was performed on a 1.5T Philips Gyroscan Intera. We retrospectively reviewed all cardiac MR scans performed from November 2003 to February 2007 at our institute to identify aortic arch anomalies. Magnetic resonance imaging included three‐dimensional (3D) sagittal volume images, cine images, short axis ventricular volumes, phase contrast flow of great vessels, and 3D gadolinium magnetic resonance angiogram. Results. Three major categories of anomalies were identified in 47 patients: double aortic arch (n = 9), right‐sided aortic arch with mirror image branching (n = 28), and aberrant right subclavian artery (n = 10). In the double aortic arch group, six patients were symptomatic, and four of them underwent a surgical division. Magnetic resonance imaging was used to plan the surgical management. In the other two groups, no patient presented with symptoms of airway or esophageal compression, and the arch abnormalities were noticed during investigation for other associated cardiac disease. However, we noticed a strong correlation with well‐defined subgroups of congenital heart disease. Right‐sided aortic arch was seen in patients with pulmonary atresia with ventricular septal defect (46.4%), tetralogy of Fallot (32.1%), and double outlet right ventricle with right atrial isomerism (14.2%). Seventy percent of the patients with aberrant right subclavian artery had aortic coarctation, and another case presented a complete aortic arch interruption. Conclusion. Magnetic resonance imaging is an important diagnostic tool in identifying anomalies of the aortic arch and its branches and can be considered the imaging technique of choice when planning surgical management, especially when there are associated cardiac anomalies.     

A case report of pulmonary artery sling and situs inversus incompletes

Rationale:Pulmonary artery sling (PAS) is a rare congenital anomaly. Associated airway anomalies and/or those of the cardiovascular system are present in about half the patients. Situs inversus is a rare disease in which organs of the chest and/or abdomen are arranged in a mirror image reversal of their normal position. Herein, we report a rare case of pulmonary artery sling and situs inversus incompletus, which has not yet been reported.Patient concerns:A 10-year-old girl was admitted because of heart murmur for more than 9 years. On physical examination, the second heart sound was prominent, and a grade 2/6 systolic murmur was heard at the left mid-sternal border. Echocardiography revealed PAS and atrial septal defect (8.6 mm). A chest computer tomography angiograph demonstrated that she had lung inversus, right aortic arch, and right lung hypoplasia in addition to PAS, with a normal positioning of the heart. The PAS intersected and twisted across the bronchus, which was obviously narrowed. The PAS was type II B, since the carina was at the T6 level without a separate right upper lobe bronchus.Diagnoses:Her final diagnosis was that of PAS, tracheal stenosis, situs inversus incompletus, right lung hypoplasia, right aortic arch, ASD and PDA.Interventions:She underwent one-stage total correction for her initial cardiovascular defects through median sternotomy under cardiopulmonary bypass support.Outcomes:She had an uneventful recovery and completely healthy following the procedure.Lessons:A thorough examination before PAS surgery was essential in discovering and carefully evaluating complicated heart and lung anomalies.     

Intravascular Lithotripsy Facilitated Percutaneous Endovascular Intervention of the Aortic Arch: A Single-Center Experience

BackgroundIntravascular lithotripsy (IVL) (Shockwave Medical, Inc., Fremont, California, USA) is a novel technology used to modify heavily calcified atherosclerotic plaque in vessels to help facilitate percutaneous coronary intervention and has been shown to be effective in treating critical lesions within the lower limbs. In addition, studies are currently underway evaluating IVL's feasibility in de novo calcified stenotic coronary arteries before stenting. The use and associated complications of IVL in other vascular territories are underreported. We report our institution's initial experience using IVL for the treatment of complex, heavily calcified lesions within the aortic arch vessels.Methods and resultsWe treated five patients with IVL of the aortic arch vessels, including the carotid (2), subclavian (2), and innominate arteries. Four of the five patients underwent successful IVL treatment and intervention without complications. One patient (carotid intervention) developed acute right eye blindness post-procedure, thought to be due to an embolic plaque, which was successfully treated with tissue plasminogen activator and intravenous heparin.ConclusionIVL offers promising technology to facilitate the treatment of complex lesions in the vessels of the aortic arch. We do not promote the use of IVL but promote prospective clinical trials to assess the safety and efficacy of this technology in this vascular territory.     

Staged Hybrid Repairs of Acute Type A Aortic Dissection Involving the Right Aortic Arch with Retroesophageal Aortic Segment

IntroductionSurgery for type A aortic dissection associated with right aortic arch is complicated because of the anatomical relationship of the aorta with the trachea and oesophagus.ReportA 67-year-old man having right aortic arch with a retroesophageal aortic arch segment suffered an acute type A aortic dissection. An intimal tear located just proximal of the Kommerell’s diverticulum. Total arch replacement and an elephant trunk insertion to cover the primary intimal tear were performed. Three months later, endovascular repair was carried out to close the primary intimal tear.DiscussionHybrid repair is the appropriate way for such an unapproachable case.     

Arteria lusoria: Developmental anatomy, clinical, radiological and surgical aspects

The left aortic arch with an aberrant right subclavian artery, or arteria lusoria, is the most common aortic arch anomaly, occuring in 0.5-2.5% of individuals. Four vessels arise sequentially from the aortic arch: the right common carotid artery, the left common carotid artery, the left subclavian artery and the aberrant right subclavian artery, which crosses upwards and to the right in the posterior mediastinum. It results from a disruption in the complex remodelling of the paired branchial arches, typically of the right dorsal aorta distal to the sixth cervical intersegmental artery. The diagnosis and differentiation of arch anomalies is based on findings at chest radiography in association with those at esophagography. It is usually asymptomatic. When symptomatic, it produces dysphagia lusoria or dyspnea and chronic coughing. Treatment is indicated for symptomatic relief of dysphagia lusoria and for prevention of complications due to aneurysmal dilatation.     

Video‐assisted Thoracoscopic Surgery: Is It a Superior Technique for the Division of Vascular Rings in Children?

Objective. The use of video‐assisted thoracoscopic surgery (VATS) is becoming increasingly common in the treatment of congenital heart defects, particularly for the division of vascular rings. We compare the short‐term outcomes of vascular ring division by VATS as opposed to open thoracotomy and discuss new issues raised by VATS division of vascular rings. Methods. Over a 3‐year period, 47 pediatric patients underwent isolated division of a vascular ring. We reviewed preoperative, operative, and postoperative data. For patients whose vascular ring contained a ligamentous or atretic segment, comparisons were made between operations performed by open thoracotomy and by VATS. Results. For the 47 patients, diagnoses included right aortic arch/aberrant left subclavian artery/left ligamentum arteriosum (25), double aortic arch/right dominant (19), and double aortic arch/left dominant (3). At the time of repair, ages ranged from 1.4 to 207 months (median 15.0) and weights ranged from 2.8 to 54.0 kg (median 11.0). The 29 patients with a vascular ring containing a ligamentous or atretic segment were included in the comparison between open thoracotomy and VATS. This included 25 patients with a right aortic arch, aberrant left subclavian artery, and ligamentum arteriosum, and 4 patients with a right dominant double aortic arch in which the left arch was atretic. Patients with patent rings requiring clamping and oversewing of the vessels were not included in the comparison. Thoracoscopic division was successful in 14/16 (88%) patients. There was no significant difference in the procedure time (P = .48) with the thoracoscopic approach. There were also similar times for intensive care unit stay (P = .25) and total length of hospital stay (P = .22). Conclusions. The division of vascular rings by VATS shows similar outcomes compared with the open thoracotomy approach. It is expected that, with an increase in comfort level and further improvements in technology, the use of VATS can be extended to include patients with other congenital heart defects.     

Symptomatic Vascular Rings in Adulthood: An Uncommon Mimic of Asthma

Symptomatic thoracic vascular rings presenting in adulthood are thought to be rare. During a 3-year time period, we diagnosed four cases of symptomatic vascular rings, which had been treated unsuccessfully for suspected asthma. Spirometry was characterized by normal forced vital capacity (FVC), forced expiratory volume in 1 sec (FEV₁), and FEV₁/FVC, decreased peak expiratory flow (PEF), and truncation of the expiratory flow volume loop. Chest radiographs revealed a right aortic arch in each case with computed tomography (CT) or magnetic resonance imaging (MRI) confirming the diagnosis of a vascular ring. The specific abnormalities consisted of right aortic arch with mirror branching of the main arteries and persistent ligamentum arteriosum; right aortic arch with diverticulum and a fibrous embryonic left arch; right aortic arch with aberrant left subclavian artery arising from a diverticulum of Kommerell; and a right aortic arch with persistent ligamentum arteriosum. Although they are uncommon, vascular rings first presenting in adulthood as a mimic of asthma are not rare. This diagnosis should be considered in adults when abnormal truncation of the flow-volume loop occurs or when radiographic aortic arch abnormalities are found.     

Right Aortic Arch and Coarctation: A Rare Association

Objectives. Understand anatomical and clinical correlatives to coarctation in right aortic arch. Background. Coarctation of the aorta is rare in patients with a functional right aortic arch. We reviewed a single institutional experience, examining associated diagnoses, diagnostic methodology, and surgical approaches. Methods. A retrospective study was performed of our echocardiographic, magnetic resonance imaging, catheterization, and surgical databases from 1988 to 2001. Results. Of 240 patients with right aortic arch, 10 (4.1%) had coarctation, constituting 1.9% of all native coarctations (n = 524). Nine (90%) had long‐segment hypoplasia. Six (60%) had an aberrant left subclavian artery or retroesophageal diverticulum, 3 (30%) had mirror image branching, and 1 (10%) had a double arch with an atretic left arch. Other congenital heart defects were seen in 6 (60%) comprising 3 with ventricular septal defects, and one each with double‐outlet right ventricle, cor triatriatum, and pulmonary valve abnormality. No patients with long‐segment hypoplasia had bicuspid aortic valve. Six (60%) had vascular rings, and 5 (50%) had other associated syndromes. Magnetic resonance imaging and/or echocardiography successfully diagnosed all of these patients. Although long‐segment right aortic arch coarctation courses behind the trachea posteriorly, only 2 needed an extra‐anatomic (jump) graft; the remainders were repaired with patch angioplasty. Conclusion. Coarctation with right aortic arch is rare, constituting 4.1% of all patients with right aortic arch, compared with 5–8% of patients with left aortic arch and congenital heart disease. Nearly all had long‐segment hypoplasia without bicuspid aortic valve, and half were part of other syndrome complexes. This association can be diagnosed noninvasively and can often be repaired by patch angioplasty.     

Diagnostic problems in fetal visceral heterotaxy syndrome. Sonography vs. autopsy

IntroductionVisceral heterotaxy syndromes (VHS) are defined as abnormalities of the determination of left-right symmetry, described as left or right atrial isomerism (LAI, RAI) [11]. Some cases do not follow classical patterns and may cause diagnostic problems. The aim of this study is to determine whether their features can be helpful or misleading in the diagnosis of VHS.Material and methodsThe study was based on 6 cases diagnosed sonographically and/or in autopsy. The results of examinations were re-evaluated and compared.ResultsTwo of 6 fetuses were diagnosed to have right atrial isomerism (RAI), 3 presented left atrial isomerism (LAI) and one case was diagnosed as VHS. Cardiovascular anomalies comprised: abnormal systemic venous connections (6/6), partial anomalous pulmonary venous drainage (PAPVD) (2/6), complete atrioventricular septal defect (cAVSD) (2/6), ventricular left-hand pattern (2/6), ventriculo-arterial discordance (1/6), tricuspid atresia (1/6), mitral atresia (1/6) and tetralogy of Fallot (ToF) (1/6). Fetuses diagnosed as LAI presented complete heart block. In 2 cases of RAI and in 3 cases of LAI isomeric anatomy of the atrial appendages was observed. None of fetuses with LAI presented “polysplenia” and none of fetuses with RAI presented “asplenia”. Lungs and main bronchi were isomeric in 3 cases of LAI and in no cases of RAI. One fetus with otocephaly presented atrial situs solitus and multiple cardiac anomalies, situs ambiguus of lungs and bronchi and situs solitus of the abdominal viscera.ConclusionsThere are characteristic features of left and right isomerism, and they may be present in various forms. In some cases extracardiac features of VHS can be seen only on autopsy.     

Novel application of four-dimensional sonography with B-flow imaging and spatiotemporal image correlation in the assessment of fetal congenital heart defects

Aims: To evaluate the role of four‐dimensional (4D) ultrasound with B‐flow imaging and spatiotemporal image correlation (STIC) in the evaluation of normal fetal heart and congenital heart disease during pregnancy. Methods: Volume data sets of the fetal heart were acquired with automated transverse and longitudinal sweeps of the anterior chest wall. We studied 31 normal fetuses and 28 fetuses with congenital heart disease (6 with double‐outlet right ventricle, 5 with complete transposition of great arteries, 8 with tetralogy of Fallot, 3 with right aortic arch, 2 with persistent left superior vena cava, 3 with truncus arteriosus communis, and 1 with interruption of aortic arch) at gestation ages ranging from 18 to 39 weeks using transabdominal 4D B‐flow sonography with STIC (4D BF‐STIC). Results: Four‐dimensional BF‐STIC demonstrated dynamic angiographic features in both normal and abnormal fetal hearts. Four‐dimensional BF‐STIC images could not be obtained in two normal fetuses at 18.9 and 35.6 weeks because of the high fetal heart rate and inappropriate fetal position. Of the other 29 fetuses all extracardiac vessels such as aorta, pulmonary artery, ductus arteriosus, inferior vena cava, and ductus venosus could be detected on reconstructed images. In seven normal cases, a 4D image was recorded to allow simultaneous visualization of all four pulmonary veins. In the 28 fetuses with cardiac anomalies, 4D sonography with B‐flow imaging and STIC detected the “digital casts” of the outflow tracts, great arteries, and veins draining into the heart. These results demonstrate spatial relationship among these structures which provide important anatomical information. Conclusion: Four‐dimensional BF‐STIC provides a means of real time three‐dimensional evaluation of fetal extracardiac hemodynamics in the second and third trimesters. This novel technique assists in the evaluation of fetal cardiac hemodynamics and may play an important role in future fetal cardiac research and in the identification of anatomical features of different congenital cardiac anomalies. (Echocardiography 2012;29:614‐619)     

Aortic arch anomaly presenting as exercise-induced asthma

We present the case of a young woman with a right aortic arch who first became symptomatic when she began a vigorous exercise program. Her symptoms were very suggestive of exercise-induced bronchospasm. Her flow-volume curves, however, showed evidence of variable intrathoracic large airways obstruction. A magnetic resonance imaging scan confirmed the presence of severe tracheal narrowing caused by her right aortic arch.     

Thyroid hemiagenesis associated with the right aortic arch

The case of a 38-year-old woman with left thyroid hemiagenesis associated with the right aortic arch is presented. The diagnosis of hemiagenesis was established by isotopic and ultrasonic imaging, and also by angiographically defined absence of the left thyroid arteries. The aortogram revealed a right aortic arch with isolation of the left subclavian artery from the aorta. Although the significance and mechanism of the concomitant development of these anomalies is unknown, this case may be the first report in the literature.     

Real-Time Cardiac Catheter Navigation on Three-Dimensional CT Images

Introduction: Targets for ablation of atrial fibrillation, atrial flutter, and non-idiopathic ventricular tachycardia are increasingly being selected based on anatomic considerations. Because fluoroscopy provides only limited information about the relationship between catheter positions and cardiac structures, and is associated with radiation risk, other approaches to mapping may be beneficial. Methods: The spatial and temporal information of an electromagnetic catheter tip position sensing system (Magellan, Biosense Inc.) was superimposed on a three-dimensional (3D) CT of the chest in swine using fiducial markers for image registration. Position and orientation of a 6 French catheter with an electromagnetic sensor was displayed in real-time on a corresponding 3D-CT. Catheter navigation within the heart and the great vessels was guided by detailed knowledge about catheter location in relation to cardiac anatomy. Results: Anatomic structures including the atrial septum, pulmonary veins, and valvular apparatus were easily identified and used to direct catheter navigation. During the right heart examination, the catheter was navigated through the superior and inferior vena cava to predetermined anatomic locations in right atrium, right ventricle and pulmonary artery. The ablation catheter was also navigated successfully from the aorta through the aortic valve in the left ventricle. No complication was encountered during the experiments. The accuracy and precision of this novel approach to mapping was 4.69 ± 1.70 mm and 2.22 ± 0.69 mm, respectively. Conclusions: Real-time display of catheter position and orientation on 3D-CT scans allows accurate and precise catheter navigation in the heart. The detailed anatomic information may improve anatomically based procedures like pulmonary vein ablation and has the potential to decrease radiation times.     

Retroesophageal Brachiocephalic Artery Assessed by Magnetic Resonance Imaging: A Case Report and Literature Review

A right aortic arch with a retroesophageal brachiocephalic artery is a very rare type of vascular ring. We present a case report along with a review of published cases to date. Twelve publications from 1968-2014 describe a retroesophageal brachiocephalic artery in a total of 13 patients. The mean age at diagnosis was 8.7 ± 16 years. Four of the 13 patients were boys. Nearly half of the patients were symptomatic, with dysphagia or respiratory difficulties. Ten patients (77%) had associated congenital heart defects. Of the 13 patients with retroesophageal brachiocephalic artery, 12 had a right aortic arch, and only 1 had a left aortic arch associated with complex congenital heart disease.Investigations used in the diagnosis of the vascular ring include angiography, esophagography, echocardiography, and computed tomography. Only 2 patients had the diagnosis confirmed with magnetic resonance imaging (MRI), but this was in the setting of complex congenital heart disease.In conclusion, a right aortic arch with a retroesophageal left brachiocephalic artery is an extremely rare form of vascular ring and is often seen in association with other forms of congenital heart disease. Cardiac MRI can be used as a primary diagnostic modality for both the assessment of the vascular ring anatomy and the hemodynamics of associated cardiac malformations in the preoperative setting.     

EUS imaging of the arteria lusoria: case series and review

BACKGROUND: The arteria lusoria is an aberrant right subclavian artery that passes dorsally between the esophagus and spine after branching off from the aortic arch. The role of endoscopic ultrasonography (EUS) in the diagnosis of the arteria lusoria has not been established. The possibility of demonstrating this vascular anomaly with EUS and estimating its prevalence was assessed. METHODS: From December 1991 to September 1998, EUS of the upper gastrointestinal tract was performed in 3334 consecutive patients for various reasons. After imaging of the target organ(s), the echoendoscope was slowly pulled back while imaging the mediastinum proximally to the superior aspect of the aortic arch. In every patient, the area of the aortic arch was carefully inspected and special attention was given to vessels crossing from left to right between the esophagus and spine. RESULTS: During the study period, an arteria lusoria was discovered in 12 of 3334 patients (0.36%: 95% CI [0.16%, 0.56%]). There were 6 men and 6 women; mean age was 64+/-14.7 years. In all 12 patients the arteria lusoria passed between the esophagus and spine. In none of the patients could symptoms be attributed to the presence of this anatomic variant. CONCLUSIONS: An arteria lusoria can be detected with upper gastrointestinal EUS and was found in 0.36% of patients. EUS can accurately demonstrate this vascular anomaly.     

A New Experimental Animal Protocol for the Direct Viewing of Endovascular Interventions Involving the Ascending Aorta and Aortic Arch

IntroductionThis article presents an experimental model for direct viewing of endovascular procedures within the ascending aorta and aortic arch.ReportThe model consisted of a porcine heart and aorta connected to a pump providing continuous or pulsatile irrigation with saline set in a waterproof basin. Aortic branches were sutured or clamped. A telescope connected to a thoracoscopic camera was inserted through the apex into the left ventricle and advanced into the arch through the aortic valve.DiscussionThis protocol provided excellent image quality, and could be used to improve endovascular procedures and establish safer protocols for use in humans.     

The Impact of Aortic Arch Geometry on Flow Dynamics Using a Simplified Approach with Magnetic Resonance Velocity Mapping

Background. We sought to determine, in vivo, the impact of aortic arch geometry on flow dynamics, which affects overall cardiovascular energetics and has implications for organ perfusion and Doppler flow calculations. Methods. Twenty‐seven patients (13 with left and 14 with right aortic arches) underwent magnetic resonance phase‐encoded velocity mapping in the ascending and descending aorta. The cross‐sectional area were divided into 4 equal quadrants aligned along the long axis of the aorta for analysis. Significance P < .05. Results. In the ascending aorta, there was a significantly higher total flow throughout the cardiac cycle in the posterior and leftward quadrant of right aortic arch than left aortic arch (P = .007) that was compensated for by significantly lower flow in anterior and rightward quadrant of right aortic arch than left aortic arch (P = .02). In the right aortic arch, maximum velocity (100 ± 14 cm/second) occurred in 7/9 patients in the right half while in left aortic arch, maximum velocity (107 ± 20 cm/second) occurred in 13/15 in the left half. In the descending aorta, whether left aortic arch or right aortic arch, the posterior half appeared to have greater flow than the anterior half. Conclusion. Right aortic arch geometry impacts flow dynamics in the ascending aorta whereas it is not altered in the descending aorta, where flow is predominantly in the posterior half. The sidedness of the aortic arch determined the location of maximum velocity. Alternatively, this also may suggest that hemodynamics could have played a role in the development of right aortic arch in certain individuals.     

Modified “in situ” arch replacement with an integrative frozen elephant trunk device for acute type A aortic dissection

BackgroundTotal arch replacement (TAR) and frozen elephant trunk (FET) has been proposed as the primary arch repair method for acute type A aortic dissection (aTAAD). We introduce a modified “in situ” arch replacement with an integrative FET device for aTAAD.MethodsFrom January 2018 to December 2019, 507 aTAAD patients from Nanjing Drum Tower Hospital received surgical therapy; among them, 57 patients with modified island total arch replacement (MiTAR) and 138 patients with TAR were enrolled. Marfan syndrome, primary intimal tears located in the large curve of aortic arch +/− or supra-arch vessels and dilated aortic arch (≥45 mm) were contraindications for MiTAR. MiTAR involves two steps: first, insert a FET device into the descending aorta during the hypothermic circulation arrest period; second, anastomose the remaining “island” arch with the prosthetic vessel and the proximal part of the FET.ResultsMiTAR patients were older than those receiving TAR (52.1 vs. 48.9 years; P=0.078), but their baseline demographics and manifestations of organ ischaemia were nearly the same. The times of cardiopulmonary bypass (CPB), aortic clamp and hypothermic circulation arrest were significantly shorter with MiTAR (209.3 vs. 267.1 minutes, P=0.000; 147.9 vs. 190.0 minutes, P=0.000; 34.0 vs. 39.4 minutes, P=0.003, respectively). The volumes of intraoperative transfusions of red blood cells (RBCs), fresh frozen plasma (FFP), platelets and cryoprecipitates were significantly lower in MiTAR (5.9 vs. 8.5 units, P=0.000; 758.3 vs. 930.4, P=0.000; 12.5 vs. 17.5 mL, P=0.000; 9.4 vs. 16.6 units, P=0.000). The 30-day mortality was 7.0% (4/57) for MiTAR and 11.6% (16/138) for TAR. One patient died and no patient received reintervention during the follow-up period, while the size of several levels of aorta showed a decreasing trend.ConclusionsMiTAR is a simplified approach to TAR that reduces the surgical trauma while achieving aortic reshaping effects.     

Body perfusion in surgery of the aortic arch

We propose a new cannulation and perfusion technique for aortic arch surgery, in order to achieve continuous antegrade total-body perfusion under moderate hypothermia.The heart and the aortic arch are exposed through a median sternotomy. Cardiopulmonary bypass is established from the right atrium to the right axillary artery. At 26 degrees C of body temperature, the supra-aortic vessels are clamped, the ascending aorta and the aortic arch are incised, and a cuffed endotracheal cannula, connected to an arterial line geared by a separate roller pump, is inserted into the descending thoracic aorta. Perfusion is started in the distal body, while the brain is perfused through the right axillary artery. Once the aortic arch has been replaced with a Dacron graft and the supra-aortic vessels have been reimplanted on the graft, the arterial line in the descending thoracic aorta is clamped and removed. The supra-aortic vessel clamps are removed, the proximal part of the Dacron graft is clamped, and systemic cardiopulmonary bypass is resumed via the right axillary artery.From January 2002 through December 2005, this technique was used in 12 consecutive patients on an emergency basis, due to acute aortic dissection that required total arch replacement. Within the first 30 postoperative days, 1 patient (8.3%) died, and no patient had permanent neurologic deficits.This simple technique ensures a full-flow antegrade total-body perfusion during all phases of the surgical procedure, thereby eliminating ischemia-reperfusion syndrome and yielding excellent clinical results.