How to make a total aortic arch replacement without global circulatory arrest. The branch first technique

The surgical approach of the aortic arch, due to its technical and tactical complexity and possible complications, is still one of the most challenging interventions of cardiac surgery. Before facing an aortic arch operation, planning of the movement of clamps is of utmost importance to achieve this surgery with almost no circulatory arrest. We herein report a 62-year-old man in septic shock with a biliary etiology. A computed tomography diagnosed a chronic aneurysm with dissection of the ascending aorta and the aortic arch. A transesophageal echocardiogram confirmed the dissection and revealed a moderate aortic regurgitation, and a severe left ventricular dysfunction. A coronary angiography showed a significant right coronary artery stenosis. Once the biliary disease was solved, it was planned the surgery for the aorta. Operative plan: Aortic arch replacement with the branch-first technique, ascending aorta and aortic valve replacement, and a venous bypass to the right coronary artery. The patient was discharged after 16 days. (C) 2017 Sociedad Espanola de Cirugia Toracica-Cardiovascular. Published by Elsevier Espana, S.L.U.