We describe a modified access technique for the proximal (open) part of single stage hybrid exclusion of aneurysm of the aortic arch.
3 patients had a bifurcated Dacron graft for the innominate and left subclavian arteries and an additional end-to-side anastomosis of the left common carotid artery on the limb to the left subclavian artery. With our modification, access to the left subclavian artery is by left subclavicular incision and creation of an anterior tunnel via the left thoracic outlet from the origin of the left subclavian artery along its anatomical course to the subclavicular plane.
Advantages and disadvantages of this technique in relation to anatomy and pathology.
A number of techniques and variations thereof are currently employed in surgery for the aortic arch.
The two –  and single-stage  hybrid management of pathologies of the aortic arch have been recently described as alternatives to the traditional ''open'' surgical technique with use of cardiopulmonary bypass (CPB), profound hypothermia and total circulatory arrest (TCA) . Variations with the use of trifurcated grafts for arch exclusion have also been reported . The primary aim of this report is to present an alternative technique of some interest: an ancillary left subclavicular incision for the left subclavian (LSC) anastomosis and use of a standard bifurcated 20 mm–10 mm Dacron graft where the left common carotid (LCC) is anastomosed end-to side (Figure 1).
Preoperative imaging with contrast thorax computed tomography is required to visualize adequately the degree of calcification of the ascending aorta and the vascular anatomy of the arch, with particular attention to the degree of calcification around the origins of head and neck vessels.
The standard preparation and draping of the patients for aortic arch surgery has been previously well described. Our approach (Figure 2) specifically combines 1. extended median sternotomy with preservation of the innominate vein and 2. left subclavicular incision cephalad to the deltopectoral groove , transection of the left pectoralis minor muscle for access and control of the distal SCA (emphasis on preserving the trunks and divisions of the left brachial plexus).
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