Operative Techniques in Surgery of the Proximal Thoracic Aorta and Aortic Arch



There is a strikingly uniform histopathology (cystic medial degeneration) inherent to most all diseases affecting the proximal thoracic aorta, and this pathology imparts a disruption of the structural integrity of the aortic wall giving rise to aneurysm formation, dissection, or rupture – the final common pathway of untreated proximal thoracic aortic disease. It is important to fully understand the clinical modes of presentation of proximal thoracic aortic disease as the surgical management and timing of intervention vary accordingly. Patient comorbidity, extent of thoracic aortic reconstruction required, and timing of surgery, all impact morbidity and mortality following proximal thoracic aortic surgery. The extent of reconstruction is predicated on the condition of the aortic root and the aortic valve, the presence of an underlying connective tissue disorder, the life expectancy of the patient, the desired anticoagulation status, the need for associated cardiac procedures, as well as surgeon experience. The ultimate outcome of patients undergoing these procedures depends on thorough preoperative surgical ­planning; meticulous myocardial, cerebral, and spinal cord protection; precise operative technique; and dutiful postoperative care. Thoracic aortic surgery is complex and mandates a seamless interaction between surgeons and cardiac anesthesiologists to ensure optimal patient outcomes.


Aortic Root Bicuspid Aortic Valve Aortic Annulus Thoracic Aortic Aneurysm Hypothermic Circulatory Arrest 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Stehbens WE. History of aneurysms. Med Hist. 1958;2(4):274–280.PubMedGoogle Scholar
  2. 2.
    Castiglioni A. In: Knopf AA, ed. A History of Medicine. New York: Knopf; 1941:370.Google Scholar
  3. 3.
    Oschner A. Discussion. Surgical considerations of intrathoracic aneurysms of the aorta and great vessels. Ann Surg. 1952;135(5):686.Google Scholar
  4. 4.
    Cooley DA, DeBakey ME. Surgical considerations of intrathoracic aneurysms of the aorta and great vessels. Ann Surg. 1952;135(5):660–680.PubMedCrossRefGoogle Scholar
  5. 5.
    Craaford C, Nylin G. Congenital coarctation of the aorta and its surgical treatment. J Thorac Surg. 1945;14:347.Google Scholar
  6. 6.
    Gross R, Hurwitt E, Bill A. Preliminary observation on the use of human arterial grafts in the treatment of certain cardiovascular defects. N Engl J Med. 1948; 239:578.PubMedCrossRefGoogle Scholar
  7. 7.
    Cooley DA, DeBakey ME. Successful resection of aneurysm of thoracic aorta and replacement by graft. JAMA. 1953;152:673.Google Scholar
  8. 8.
    De Bakey ME. Cooley DA, Crawford ES, et al. Clinical application of a new flexible knitted dacron arterial substitute.Am Surg. 1963;27(4):779–783.PubMedGoogle Scholar
  9. 9.
    Cooley DA, De Bakey ME. Resection of entire ascending aorta in fusiform aneurysm using cardiac bypass. J Am Med Assoc. 1956;162(12):1158–1159.PubMedGoogle Scholar
  10. 10.
    Starr A, Edwards ML, McCord CW, Grisworld HE. Aortic replacement: clinical experience with a semirigid ball-valve prosthesis. Circulation. 1963;27(4): 779–783.Google Scholar
  11. 11.
    Bentall H, De Bono A. A technique for complete replacement of the ascending aorta. Thorax. 1968;23(4):338–339.PubMedCrossRefGoogle Scholar
  12. 12.
    Kouchoukos NT, Dougenis D. Surgery of the thoracic aorta [see comment]. N Engl J Med. 1997;336(26):1876–1888.PubMedCrossRefGoogle Scholar
  13. 13.
    Johnston KW, Rutherford RB, Tilson MD, et al. Suggested standards for reporting on arterial aneurysms. Subcommittee on Reporting Standards for Arterial Aneurysms, Ad Hoc Committee on Reporting Standards, Society for Vascular Surgery and North American Chapter, International Society for Cardiovascular Surgery [see comment]. J Vasc Surg 1991;13(3):452–458.Google Scholar
  14. 14.
    Clouse WD, Hallett JW Jr, Schaff HV, et al. Improved prognosis of thoracic aortic aneurysms: a population-based study. JAMA. 1998;280(22):1926–1929.PubMedCrossRefGoogle Scholar
  15. 15.
    Coady MA, Rizzo JA, Goldstein LJ, et al. Natural ­history, pathogenesis, and etiology of thoracic aortic aneurysms and dissections. Cardiol Clin. 1999;17(4):615–635. vii.PubMedCrossRefGoogle Scholar
  16. 16.
    Vilacosta I, Roman JA. Acute aortic syndrome. Heart. 2001;85(4):365–368.PubMedCrossRefGoogle Scholar
  17. 17.
    Reece TB, Green GR, Kron IL. Cardiac surgery in the adult. In: Cohn L, ed. Aortic Dissection. New York: McGraw-Hill; 2008.Google Scholar
  18. 18.
    Sundt TM, Sundt TM. Intramural hematoma and ­penetrating aortic ulcer. Curr Opin Cardiol. 2007;22(6):504–509.PubMedCrossRefGoogle Scholar
  19. 19.
    Stanson AW, Kazmier FJ, Hollier LH, et al. Penetrating atherosclerotic ulcers of the thoracic aorta: natural history and clinicopathologic correlations. Ann Vasc Surg. 1986;1(1):15–23.PubMedGoogle Scholar
  20. 20.
    Bickerstaff LK, Pairolero PC, Hollier LH, et al. Thoracic aortic aneurysms: a population-based study. Surgery. 1982;92(6):1103–1108.PubMedGoogle Scholar
  21. 21.
    Svensjo S, Bengtsson H, Bergqvist D. Thoracic and thoracoabdominal aortic aneurysm and dissection: an investigation based on autopsy. Br J Surg. 1996;83(1):68–71.PubMedCrossRefGoogle Scholar
  22. 22.
    Pannu H, Avidan N, Tran-Fadulu V, et al. Genetic basis of thoracic aortic aneurysms and dissections: potential relevance to abdominal aortic aneurysms. Ann NY Acad Sci. 2006;1085:242–255.PubMedCrossRefGoogle Scholar
  23. 23.
    Guo DC, Papke CL, He R, et al. Pathogenesis of thoracic and abdominal aortic aneurysms. Ann NY Acad Sci. 2006;1085:339–352.PubMedCrossRefGoogle Scholar
  24. 24.
    Wolinsky H, Glagov S. A lamellar unit of aortic medial structure and function in mammals. Circ Res. 1967;20(1):99–111.PubMedGoogle Scholar
  25. 25.
    Pearce WH, Slaughter MS, LeMaire S, et al. Aortic diameter as a function of age, gender, and body ­surface area. Surgery. 1993;114(4):691–697.PubMedGoogle Scholar
  26. 26.
    Lesauskaite V, Tanganelli P, Sassi C, et al. Smooth muscle cells of the media in the dilatative pathology of ascending thoracic aorta: morphology, immunoreactivity for osteopontin, matrix metalloproteinases, and their inhibitors. Hum Pathol. 2001;32(9):1003–1011.PubMedCrossRefGoogle Scholar
  27. 27.
    Dietz HC, Cutting GR, Pyeritz RE, et al. Marfan syndrome caused by a recurrent de novo missense mutation in the fibrillin gene. Nature. 1991;352(6333):337–339.PubMedCrossRefGoogle Scholar
  28. 28.
    Kainulainen K, Pulkkinen L, Savolainen A, et al. Location on chromosome 15 of the gene defect causing Marfan syndrome. N Engl J Med. 1990;323(14):935–939.PubMedCrossRefGoogle Scholar
  29. 29.
    Schoen F. Robbins and Cotran pathologic basis of disease. In: Kumar V, Abbas AK, Fausto N, eds. Blood Vessels. Philadelphia, PA: Elsevier Saunders; 2005.Google Scholar
  30. 30.
    Pyeritz RE, McKusick VA. The Marfan syndrome: diagnosis and management. N Engl J Med. 1979;300(14):772–777.PubMedCrossRefGoogle Scholar
  31. 31.
    Marsalese DL, Moodie DS, Vacante M, et al. Marfan’s syndrome: natural history and long-term follow-up of cardiovascular involvement. J Am Coll Cardiol. 1989;14(2):422–428.PubMedCrossRefGoogle Scholar
  32. 32.
    Pyeritz RE, Wappel MA. Mitral valve dysfunction in the Marfan syndrome. Clinical and echocardiographic study of prevalence and natural history. Am J Med. 1983;74(5):797–807.PubMedCrossRefGoogle Scholar
  33. 33.
    Murdoch JL, Walker BA, Halpern BL, et al. Life expectancy and causes of death in the Marfan syndrome. N Engl J Med. 1972;286(15):804–808.PubMedCrossRefGoogle Scholar
  34. 34.
    Oderich GS, Panneton JM, Bower TC, et al. The spectrum, management and clinical outcome of Ehlers-Danlos syndrome type IV: a 30-year experience. J Vasc Surg. 2005;42(1):98–106.PubMedCrossRefGoogle Scholar
  35. 35.
    Loeys BL, Schwarze U, Holm T, et al. Aneurysm ­syndromes caused by mutations in the TGF-beta receptor. N Engl J Med. 2006;355(8):788–798.PubMedCrossRefGoogle Scholar
  36. 36.
    Tadros TM, Klein MD, Shapira OM, et al. Ascending aortic dilatation associated with bicuspid aortic valve: pathophysiology, molecular biology, and clinical implications. Circulation. 2009;119(6):880–890.PubMedCrossRefGoogle Scholar
  37. 37.
    Della Corte A, Bancone C, Quarto C, et al. Predictors of ascending aortic dilatation with bicuspid aortic valve: a wide spectrum of disease expression. Eur J Cardio-Thorac Surg. 2007;31(3):397–404.CrossRefGoogle Scholar
  38. 38.
    Larson EW, Edwards WD. Risk factors for aortic dissection: a necropsy study of 161 cases. Am J Cardiol. 1984;53(6):849–855.PubMedCrossRefGoogle Scholar
  39. 39.
    Keane MG, Wiegers SE, Plappert T, et al. Bicuspid aortic valves are associated with aortic dilatation out of proportion to coexistent valvular lesions. Circulation. 2000;102(19 Suppl 3):III35–III39.PubMedGoogle Scholar
  40. 40.
    Pachulski RT, Weinberg AL, Chan KL. Aortic aneurysm in patients with functionally normal or minimally stenotic bicuspid aortic valve. Am J Cardiol. 1991;67(8):781–782.PubMedCrossRefGoogle Scholar
  41. 41.
    Russo CF, Mazzetti S, Garatti A, et al. Aortic complications after bicuspid aortic valve replacement: long-term results. Ann Thorac Surg. 2002;74(5):S1773–S1776.PubMedCrossRefGoogle Scholar
  42. 42.
    Borger MA, Preston M, Ivanov J, et al. Should the ascending aorta be replaced more frequently in patients with bicuspid aortic valve disease? J Thorac Cardiovasc Surg. 2004;128(5):677–683.PubMedGoogle Scholar
  43. 43.
    Yasuda H, Nakatani S, Stugaard M, et al. Failure to prevent progressive dilation of ascending aorta by aortic valve replacement in patients with bicuspid aortic valve: comparison with tricuspid aortic valve. Circulation. 2003;108(Suppl 1):II291–II294.PubMedGoogle Scholar
  44. 44.
    Nataatmadja M, West M, West J, et al. Abnormal extracellular matrix protein transport associated with increased apoptosis of vascular smooth muscle cells in marfan syndrome and bicuspid aortic valve thoracic aortic aneurysm. Circulation. 2003;108(Suppl 1):II329–II334.PubMedGoogle Scholar
  45. 45.
    Fedak PW, de Sa MP, Verma S, et al. Vascular matrix remodeling in patients with bicuspid aortic valve malformations: implications for aortic dilatation. J Thorac Cardiovasc Surg. 2003;126(3):797–806.PubMedCrossRefGoogle Scholar
  46. 46.
    Perko MJ, Norgaard M, Herzog TM, et al. Unoperated aortic aneurysm: a survey of 170 patients. Ann Thorac Surg. 1995;59(5):1204–1209.PubMedCrossRefGoogle Scholar
  47. 47.
    Pressler V, McNamara JJ. Thoracic aortic aneurysm: natural history and treatment. J Thorac Cardiovasc Surg. 1980;79(4):489–498.PubMedGoogle Scholar
  48. 48.
    Coady MA, Rizzo JA, Hammond GL, et al. What is the appropriate size criterion for resection of thoracic aortic aneurysms? J Thorac Cardiovasc Surg. 1997;113(3):476–491.PubMedCrossRefGoogle Scholar
  49. 49.
    Meszaros I, Morocz J, Szlavi J, et al. Epidemiology and clinicopathology of aortic dissection. Chest. 2000;117(5):1271–1278.PubMedCrossRefGoogle Scholar
  50. 50.
    Anagnostopoulos CE, Prabhakar MJ, Kittle CF. Aortic dissections and dissecting aneurysms. Am J Cardiol. 1972;30(3):263–273.PubMedCrossRefGoogle Scholar
  51. 51.
    Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA. 2000;283(7):897–903.PubMedCrossRefGoogle Scholar
  52. 52.
    Gilon D, Mehta RH, Oh JK, et al. Characteristics and in-hospital outcomes of patients with cardiac tamponade complicating type A acute aortic dissection. Am J Cardiol. 2009;103(7):1029–1031.PubMedCrossRefGoogle Scholar
  53. 53.
    Coady MA, Davies RR, Roberts M, et al. Familial patterns of thoracic aortic aneurysms. Arch Surg. 1999;134(4):361–367.PubMedCrossRefGoogle Scholar
  54. 54.
    Davies RR, Goldstein LJ, Coady MA, et al. Yearly rupture or dissection rates for thoracic aortic aneurysms: simple prediction based on size. Ann Thorac Surg. 2002;73(1):17–27.PubMedCrossRefGoogle Scholar
  55. 55.
    Davies RR, Kaple RK, Mandapati D, et al. Natural history of ascending aortic aneurysms in the setting of an unreplaced bicuspid aortic valve. Ann Thorac Surg. 2007;83(4):1338–1344.PubMedCrossRefGoogle Scholar
  56. 56.
    Coady MA, Rizzo JA, Hammond GL, et al. Surgical intervention criteria for thoracic aortic aneurysms: a study of growth rates and complications. Ann Thorac Surg. 1999;67(6):1922–1926.PubMedCrossRefGoogle Scholar
  57. 57.
    Ergin MA, Spielvogel D, Apaydin A, et al. Surgical treatment of the dilated ascending aorta: when and how? Ann Thorac Surg. 1999;67(6):1834–1839.PubMedCrossRefGoogle Scholar
  58. 58.
    Davies RR, Gallo A, Coady MA, et al. Novel measurement of relative aortic size predicts rupture of thoracic aortic aneurysms. Ann Thorac Surg. 2006;81(1):169–177.PubMedCrossRefGoogle Scholar
  59. 59.
    Pape LA, Tsai TT, Isselbacher EM, et al. Aortic dia­meter  >  or  =  5.5 cm is not a good predictor of type A aortic dissection: observations from the International Registry of Acute Aortic Dissection (IRAD). Circulation. 2007;116(10):1120–1127.PubMedCrossRefGoogle Scholar
  60. 60.
    Hirose Y, Hamada S, Takamiya M. Predicting the growth of aortic aneurysms: a comparison of linear vs exponential models. Angiology. 1995;46(5):413–419.PubMedCrossRefGoogle Scholar
  61. 61.
    Dapunt OE, Galla JD, Sadeghi AM, et al. The natural history of thoracic aortic aneurysms. J Thorac Cardiovasc Surg. 1994;107(5):1323–1332.PubMedGoogle Scholar
  62. 62.
    Masuda Y, Takanashi K, Takasu J, et al. Expansion rate of thoracic aortic aneurysms and influencing ­factors. Chest. 1992;102(2):461–466.PubMedCrossRefGoogle Scholar
  63. 63.
    Albornoz G, Coady MA, Roberts M, et al. Familial thoracic aortic aneurysms and dissections–incidence, modes of inheritance, and phenotypic patterns. Ann Thorac Surg. 2006;82(4):1400–1405.PubMedCrossRefGoogle Scholar
  64. 64.
    Michel PL, Acar J, Chomette G, et al. Degenerative aortic regurgitation. Eur Heart J. 1991;12(8):875–882.PubMedGoogle Scholar
  65. 65.
    Prenger K, Pieters F, Cheriex E. Aortic dissection after aortic valve replacement: incidence and consequences for strategy. J Card Surg. 1994;9(5):495–498.PubMedCrossRefGoogle Scholar
  66. 66.
    Yu T, Zhu X, Tang L, et al. Review of CT angio-graphy of aorta. Radiol Clin North Am. 2007; 45(3):461–483.PubMedCrossRefGoogle Scholar
  67. 67.
    Sakamoto I, Sueyoshi E, Uetani M, et al. MR imaging of the aorta. Radiol Clin North Am. 2007; 45(3):485–497.PubMedCrossRefGoogle Scholar
  68. 68.
    Marckmann P, Skov L, Rossen K, et al. Nephrogenic systemic fibrosis: suspected causative role of gadodiamide used for contrast-enhanced magnetic resonance imaging. J Am Soc Nephrol. 2006;17(9):2359–2362.PubMedCrossRefGoogle Scholar
  69. 69.
    Coselli JS, LeMaire SA, Koksoy C. Thoracic aortic anastomoses. Oper Tech Thorac Cardiovasc Surg. 2000;5(4):261–265.Google Scholar
  70. 70.
    Olson LJ, Subramanian R, Edwards WD. Surgical pathology of pure aortic insufficiency: a study of 225 cases. Mayo Clin Proc. 1984;59(12):835–841.PubMedGoogle Scholar
  71. 71.
    David TE, Feindel CM, Armstrong S, et al. Replacement of the ascending aorta with reduction of the diameter of the sinotubular junction to treat aortic insufficiency in patients with ascending aortic aneurysm. J Thorac Cardiovasc Surg. 2007;133(2):414–418.PubMedCrossRefGoogle Scholar
  72. 72.
    Downing SW, Kouchoukos NT. Ascending aotic aneurysm. In: Edmunds LHJ, ed. Cardiac Surgery in the Adult. New York: McGraw-Hill; 1997:1163.Google Scholar
  73. 73.
    Gleason TG, David TE, Coselli JS, et al. St. Jude Medical Toronto biologic aortic root prosthesis: early FDA phase II IDE study results. Ann Thorac Surg. 2004;78(3):786–793.PubMedCrossRefGoogle Scholar
  74. 74.
    Ross DN. Replacement of aortic and mitral valves with a pulmonary autograft. Lancet. 1967;2(7523):956–958.PubMedCrossRefGoogle Scholar
  75. 75.
    Somerville J, Ross DN. Pulmonary autograft for replacement of the aortic valve. G Ital Cardiol. 1974; 4(4):413–425.PubMedGoogle Scholar
  76. 76.
    Elkins RC. Pulmonary autograft. In: Franco KL, Verrier ED, eds. Advanced Therapy in Cardiac Surgery. Hamilton: BC Decker; 2003:156–167.Google Scholar
  77. 77.
    Sarsam MA, Yacoub M. Remodeling of the aortic valve anulus. J Thorac Cardiovasc Surg. 1993;105(3):435–438.PubMedGoogle Scholar
  78. 78.
    David TE, Feindel CM. An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta. J Thorac Cardiovasc Surg. 1992;103(4):617–621.PubMedGoogle Scholar
  79. 79.
    Patel HJ, Deeb GM, Patel HJ, et al. Ascending and arch aorta: pathology, natural history, and treatment. Circulation. 2008;118(2):188–195.PubMedCrossRefGoogle Scholar
  80. 80.
    Yacoub MH, Gehle P, Chandrasekaran V, et al. Late results of a valve-preserving operation in patients with aneurysms of the ascending aorta and root. J Thorac Cardiovasc Surg. 1998;115(5):1080–1090.PubMedCrossRefGoogle Scholar
  81. 81.
    Gleason TG. Current perspective on aortic valve repair and valve-sparing aortic root replacement. Semin Thorac Cardiovasc Surg. 2006;18(2):154–164.PubMedCrossRefGoogle Scholar
  82. 82.
    Demers P, Miller DC, Demers P, et al. Simple modification of “T. David-V” valve-sparing aortic root replacement to create graft pseudosinuses. Ann Thorac Surg. 2004;78(4):1479–1481.PubMedCrossRefGoogle Scholar
  83. 83.
    Pacini D, Settepani F, De Paulis R, et al. Early results of valve-sparing reimplantation procedure using the Valsalva conduit: a multicenter study. Ann Thorac Surg. 2006;82(3):865–871.PubMedCrossRefGoogle Scholar
  84. 84.
    Maselli D, De Paulis R, Scaffa R, et al. Sinotubular junction size affects aortic root geometry and aortic valve function in the aortic valve reimplantation procedure: an in vitro study using the Valsalva graft. Ann Thorac Surg. 2007;84(4):1214–1218.PubMedCrossRefGoogle Scholar
  85. 85.
    Liu X, Weale P, Reiter G, et al. Breathhold ­time-resolved three-directional MR velocity ­mapping of aortic flow in patients after aortic valve-­sparing ­surgery. J Magn Reson Imaging. 2009;29(3):569–575.PubMedCrossRefGoogle Scholar
  86. 86.
    Miller DC, Miller DC. Valve-sparing aortic root replacement: current state of the art and where are we headed? Ann Thorac Surg. 2007; 83(2):S736–S739.PubMedCrossRefGoogle Scholar
  87. 87.
    David TE, Feindel CM, Webb GD, et al. Long-term results of aortic valve-sparing operations for aortic root aneurysm. J Thorac Cardiovasc Surg. 2006;132(2):347–354.PubMedCrossRefGoogle Scholar
  88. 88.
    Schafers HJ, Aicher D, Langer F, et al. Preservation of the bicuspid aortic valve. Ann Thorac Surg. 2007;83(2):S740–S745. discussion S785–90.PubMedCrossRefGoogle Scholar
  89. 89.
    Cameron DE, Alejo DE, Patel ND, et al. Aortic root replacement in 372 Marfan patients: evolution of operative repair over 30 years. Ann Thorac Surg. 2009;87(5):1344–1349.PubMedCrossRefGoogle Scholar
  90. 90.
    Aicher D, Langer F, Kissinger A, et al. Valve-sparing aortic root replacement in bicuspid aortic valves: a reasonable option? J Thorac Cardiovasc Surg. 2004;128(5):662–668.PubMedGoogle Scholar
  91. 91.
    Patel ND, Weiss ES, Alejo DE, et al. Aortic root operations for Marfan syndrome: a comparison of the Bentall and valve-sparing procedures. Ann Thorac Surg. 2008;85(6):2003–2010.PubMedCrossRefGoogle Scholar
  92. 92.
    Griepp RB, Stinson EB, Hollingsworth JF, et al. Prosthetic replacement of the aortic arch. J Thorac Cardiovasc Surg. 1975;70(6):1051–1063.PubMedGoogle Scholar
  93. 93.
    Galla JD. Aneurysms of the aortic arch. In: Franco KL, Verrier ED, eds. Advanced Therapy in Cardiac Surgery. Hamilton: BC Decker; 2003:326–328.Google Scholar
  94. 94.
    Ergin MA, Galla JD, Lansman L, et al. Hypothermic circulatory arrest in operations on the thoracic aorta. Determinants of operative mortality and neurologic outcome. J Thorac Cardiovasc Surg. 1994;107(3):788–797.PubMedGoogle Scholar
  95. 95.
    Ergin MA, Griepp EB, Lansman SL, et al. Hypothermic circulatory arrest and other methods of cerebral protection during operations on the thoracic aorta. J Card Surg. 1994;9(5):525–537.PubMedCrossRefGoogle Scholar
  96. 96.
    Spielvogel D, Etz CD, Silovitz D, et al. Aortic arch replacement with a trifurcated graft. Ann Thorac Surg. 2007;83(2):S791–S795.PubMedCrossRefGoogle Scholar
  97. 97.
    Spielvogel D, Strauch JT, Minanov OP, et al. Aortic arch replacement using a trifurcated graft and selective cerebral antegrade perfusion. Ann Thorac Surg. 2002;74(5):S1810–S1814.PubMedCrossRefGoogle Scholar
  98. 98.
    Kazui T, Washiyama N, Muhammad BA, et al. Total arch replacement using aortic arch branched grafts with the aid of antegrade selective cerebral perfusion. Ann Thorac Surg. 2000;70(1):3–8.PubMedCrossRefGoogle Scholar
  99. 99.
    Safi HJ, Miller CC 3rd, Estrera AL, et al. Optimization of aortic arch replacement: two-stage approach. Ann Thorac Surg. 2007;83(2):S815–S818.PubMedCrossRefGoogle Scholar
  100. 100.
    Borst HG, Walterbusch G, Schaps D. Extensive ­aortic replacement using “elephant trunk” prosthesis. Thorac Cardiovasc Surg. 1983;31(1):37–40.PubMedCrossRefGoogle Scholar
  101. 101.
    Kouchoukos NT, Masetti P, Mauney MC, et al. ­One-stage repair of extensive chronic aortic dissection using the arch-first technique and bilateral ­anterior thoracotomy. Ann Thorac Surg. 2008;86(5):1502–1509.PubMedCrossRefGoogle Scholar
  102. 102.
    Kouchoukos NT, Mauney MC, Masetti P, et al. Optimization of aortic arch replacement with a one–stage approach. Ann Thorac Surg. 2007;83(2):S811–S814.PubMedCrossRefGoogle Scholar
  103. 103.
    Kouchoukos NT. One-stage repair of extensive ­thoracic aortic aneurysm using the arch-first technique and bilateral anterior thoracotomy. Oper Tech Thorac Cardiovasc Surg. 2008;13(4):229.Google Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  1. 1.Division of Cardiac Surgery, Department of SurgeryThoracic Transplantation and Mechanical Circulatory Support, Heart Transplantation Program, Scott & White Clinic, Texas A&M Helath Science Center College of Medicine, Scott & White Hospital and ClinicsTempleUSA

Personalised recommendations