INTRODUCTION

Since the first description in 1957 by DeBakey (1), aortic arch replacement has evolved due to advancements in surgical technique and adjuncts such as hypothermic circulatory arrest (HCA) and antegrade cerebral perfusion (ACP), yet the morbidity and mortality associated with surgical treatment of aortic arch aneurysms remains high (2). The anatomical relationship between the aortic arch and the important vascular structures supplying the brain must be managed carefully to avoid catastrophic neurological complications.

Though patient age, comorbidities and extent of operation predict outcome from total arch replacement, surgeon experience and proficiency contribute significantly to achieving high quality outcomes, underscoring the importance of developing a systematic and reproducible approach that encompasses thoughtful preoperative planning, meticulous surgical technique and attentive postoperative care (3). We believe that these principles allow surgical trainees to develop the abilities and confidence necessary to perform these procedures safely. Since 2007, our group has collectively performed over 1000 circulatory arrest cases, including hemiarch, partial arch and total arch replacements (both conventional and frozen elephant trunk). During this period, several residents and fellows have learned and performed the operation in part or fully, confirming the notion that this is a teachable operation. We have developed a standardized and reproducible approach that emphasizes brain, cardiac and spinal cord protection, minimizes total body circulatory arrest time, yet remains flexible to adapt the sequencing and variation of arch reconstruction to the patient’s anatomy and pathology to optimize the outcome.

Herein, we describe our approach to teaching aortic arch replacement using a variety of techniques that include innominate and axillary artery cannulation, antegrade cerebral perfusion, moderate-to-deep hypothermic circulatory arrest and both anatomic and extra anatomic arch reconstruction.