Figure 2.

Following establishment of cardiopulmonary bypass, the “branch-first” aortic arch reconstruction proceeds as follows: (A) the innominate artery is clamped proximal to its bifurcation and distal to its origin from the arch. Right hemispheric cerebral perfusion is maintained through the left common carotid and subclavian arteries via collateral channels. Apart from the circle of Willis, there is a plethora of extra-cranial collateral channels that augment cerebral perfusion during individual clamping of branch vessels. These include collateral channels between; the external and internal carotid arteries; the right and the left carotid arteries; the upper and lower body; and the subclavian and carotid arteries (4); (B) the innominate stump is ligated and the anastomosis to the first limb of the branched graft completed; (C) antegrade right hemispheric cerebral perfusion is resumed via the perfusion side arm. Left hemispheric cerebral perfusion during construction of the left common carotid anastomosis is maintained via the same collaterals described above; (D) subclavian anastomosis is completed and all three arch branches are perfused; (E) anastomosis of the arch graft to the distal arch. Note that the distal anastomoses can be performed in Zone 2 which is usually better quality tissues, allows improved access to the anastomoses and reduces the risk of recurrent laryngeal nerve injury. Antegrade flow is recommended via the “ante flow” side arm of the graft. After completion of the root anastomosis, connection of the TAPP graft to the ascending graft proceeds without interruption of cerebral perfusion.