Fig 3.

Intraoperative photographs of the second stage of repair: total arch reconstruction with frozen elephant extension. (A) Median sternotomy with right supraclavicular extension. Exposure of the ascending aorta (∗∗) is obtained. (B) Modified quadrifurcated graft 24 mm Gelweave Siena Plexus graft with three arch branches (10 × 8 × 8 mm) and a side perfusion limb. The sewing collar has been trimmed. (C) Total arch reconstruction is nearly complete. Selective antegrade cerebral perfusion is performed via a Dacron graft anastomosed to the right axillary artery and the perfusion limb is seen. The right arch limb (∗) will be tunneled beneath the strap muscles to complete the right SCA anastomosis. The middle arch limb (short downward arrow) has been anastomosed to the right common carotid artery. The left arch limb (open circle) has been anastomosed to the left common carotid artery. (D) Completed arch reconstruction. Note the innominate vein (open triangle) and ligated perfusion limb offset from the arch branches.