Total arch replacement using a stepwise distal anastomosis for arch aneurysms with distal extension

A total of 120 patients having arch to distal arch aneurysm with downstream extension underwent total arch replacement, with individual arch-vessel reconstruction through median sternotomy using a novel "stepwise" distal aortic anastomosis. Cardiopulmonary bypass was established by cannulating the right axillary artery and the ascending aorta or femoral artery. Hypothermia was at 22-28 degrees C. Through the aneurysm, the descending aorta was divided. Distal anastomosis using the stepwise technique was performed; a tube graft of length 7-12 cm was inserted into the descending aorta and anastomosed by running suture. The distal end of the inserted graft was extracted, and a further four-branched arch graft was joined to it. Selective cerebral perfusion was used for cerebral safety during arch repair. There were three hospital deaths (2.5%). Two patients (1.7%) developed permanent neurological dysfunction and three patients (2.5%) suffered transient cerebral deficits. Three patients (2.5%) required reentry for postoperative bleeding although in none of them bleeding was from the distal anastomosis site with the stepwise technique. Stepwise anastomosis is a useful and secure alternative for distal anastomosis in total arch replacement for arch to distal arch aneurysms with distal extension.