Outcomes of single-stage total arch replacement via clamshell incision

The arch-first technique combined with clamshell incision was used in 38 cases of aneurysm and aortic disease in 2008 and 2009. Extensive total arch replacement was used with clamshell incision for reconstruction of arch vessels under deep hypothermic circulatory arrest.Overall 30-day mortality was 13%. The mean operating time was approximately 8 hours. Deep hypothermia resulted in mean CPB time exceeding 4.5 hours and mean duration of circulatory arrest was 25 minutes. The overall postoperative temporary and permanent neurologic dysfunction rates were 3% and 3% for elective and 3% and 0% for emergency surgery, respectively. All patients except the five who died in hospital were discharged without nursing care after an average post-operative hospital stay of 35 days.The arch-first technique, combined with clamshell incision, provides expeditious replacement of the thoracic aorta with an acceptable duration of hypothermic circulatory arrest and minimizes the risk of retrograde atheroembolism by using antegrade perfusion.The treatment of complex aortic pathologies involving the transverse arch with extensive involvement of the descending aorta remains a surgical challenge because distal anastomosis is often impossible through conventional median sternotomy [1-3]. Several techniques have been used to overcome this challenge and these include: additional thoracotomy, the elephant trunk technique (both classical and frozen), the pull-through technique with posterior pericardiotomy, and staged repair [4-6]. Another option is proximal anastomosis with posterolateral thoracotomy, which is a popular surgical approach for Stanford type B aortic dissection [7]. However, no optimal surgical technique or approach for the treatment of such lesions has been established. Kouchoukos et al. recently reported that the single-staged, arch-first replacement technique with a clamshell incision is a safe and effective procedure for patients who require extensive reoperations for chronic e