Illustrated Technique of “Branch-First” Total Aortic Arch Replacement

Abstract

Technical aspects of aortic arch replacement have evolved over the years with significant focus on reducing the risk of operative morbidity and mortality. Recent developments in surgical methods relate to optimizing strategies for neuroprotection, distal organ perfusion and myocardial protection. We describe the branch-first technique for aortic arch replacement using a trifurcation graft with a side perfusion port (TAPP). It simplifies the delivery of continuous antegrade cerebral perfusion, and takes advantage of intracranial and extracranial networks to augment contralateral cerebral perfusion. Consequently, it allows for moderate levels of hypothermia and avoids distal circulatory arrest in many cases. In cases where distal circulatory arrest is required, it affords a longer safe duration of distal arrest and allows aortic pathology to be completely and meticulously corrected without time pressures.