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Warfarin is generally avoided during the first trimester of pregnancy because of its teratogenic effects and also during the last month of pregnancy because of bleeding concerns at the time of delivery purchase endep 10 mg otc medications via g-tube. Antiarrhythmic medications such as amiodarone and disopyramide can be used to maintain sinus rhythm and should be used in combination with a β-blocker or nondihydropyridine calcium channel blocker buy endep 25mg lowest price treatment vs cure. General recommendations include the treatment of the underlying lung disease order endep 75mg with visa treatment 2, correction of hypoxia purchase endep 75 mg mastercard treatment alternatives, and correction of acid–base imbalances. Antiarrhythmic medications with β-blocking properties such as sotalol, propafenone, and adenosine can worsen bronchospasm and are contraindicated in patients with severe bronchospastic airway disease. Ventricular rate control is usually achieved with nondihydropyridine calcium channel blockers such as verapamil and diltiazem. Electrophysiologic basis, surgical development, and clinical results of the Maze procedure for atrial flutter and atrial fibrillation. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomised non-inferiority trial. Mortality, morbidity, and quality of life after circumferential pulmonary vein ablation for atrial fibrillation: outcomes from a controlled nonrandomized long-term study. A comparison of rate control and rhythm control in patients with atrial fibrillation. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Approximately 25% of calf vein thrombi propagate (in the absence of treatment) to involve the popliteal vein or above. Phlegmasia cerulea dolens is a vascular emergency requiring leg elevation, anticoagulation, and, in select cases, thrombolysis or surgical or catheter-based thrombectomy. However, because venography is invasive and requires the use of potentially harmful contrast agents, it has largely been replaced by noninvasive tests such as duplex ultrasonography. False positives may occur when pelvic masses result in isolated noncompressibility of the common femoral veins. A positive D-dimer, however, is nonspecific, and other diagnostic testing should be performed. Value of assessment of pretest probability of deep-vein thrombosis in clinical management. No monitoring is required except in obese, pediatric, or pregnant patients or patients with renal insufficiency. Fondaparinux is contraindicated in patients with severe renal impairment (creatinine clearance < 30 mL/min) and bacterial endocarditis. Additionally, because these agents have stable pharmacodynamics (unlike warfarin), routine monitoring is not required. Systemic lysis is also an option if a catheter- directed approach is not available. Both routes carry an increased risk of systemic hemorrhage compared with standard anticoagulation alone. The risk of recurrence is low while patients are on anticoagulation; however, clinicians must weigh the risk of bleeding against the risk of new thrombosis. In patients who are managed with surveillance (serial imaging once or twice weekly for 2 to 3 weeks), anticoagulation is recommended if the thrombus extends further in the distal veins or to the proximal veins. The decision for anticoagulation or surveillance should also consider bleeding risk and patient preference. Anticoagulation is not routinely administered, but may be considered for those at higher risk for extension to the proximal veins (>5 cm length, <5 cm from the sapheno- femoral or sapheno-popliteal junction). Other less common causes include thoracic outlet syndrome, Paget–von Schröetter syndrome (also referred to as effort thrombosis), and hypercoagulable conditions including malignancy. Patients may be asymptomatic but more frequently complain of arm swelling and pain. Thrombolysis should be considered in younger patients with effort thrombosis, who have a low risk of bleeding and symptoms of acute onset. The majority of patients die because of a failure in diagnosis rather than inadequate therapy. Elevated pulmonary vascular resistance results in decreased right ventricular outflow, leading to a decrease in preload and cardiac output resulting in hypotension. Elevated right ventricular wall tension can lead to decreased right coronary artery flow and ischemia. Patients with pulmonary infarction usually present with pleuritic chest pain, dyspnea, and hemoptysis, and an audible friction rub may be heard. The majority of patients present with generalized symptoms of chest pain, dyspnea, and malaise. When present, findings are nonspecific and include pleural effusion, atelectasis, and consolidation. The classic signs, including the Westermark sign (regional oligemia), Hampton hump (pleural-based, wedge-shaped shadow), and Palla sign (enlarged right inferior pulmonary artery), are uncommon. Risk stratification using a combination of hemodynamic stability, biomarkers, and echocardiographic criteria is utilized to determine the use of catheter-directed therapies and systemic lysis. In normotensive patients, this tool can reliably distinguish between intermediate and low risk and therefore identify patients who may require further evaluation. Additionally, there is a growing body of evidence supporting early discharge or home therapy for patients at low risk. If a laboratory test for a cardiac biomarker has already been performed during initial diagnostic work-up (e. This might apply to situations in which imaging or biomarker results become available for the calculation of the clinical severity index. Thrombolysis, if (and as soon as) clinical signs of hemodynamic decompensation appear; surgical pulmonary embolectomy and percutaneous catheter-directed treatment may be considered as alternative options to systemic e thrombolysis, particularly if the bleeding risk is high. Overall, mortality was <2% at 7 days with no significant difference between groups. The group receiving thrombolytics was less likely to develop hemodynamic decompensation; however, this was at the cost of significantly increased risk of intracranial and other major bleeding. Based on these results, routine use of systemic thrombolysis is not recommended in normotensive patients at intermediate risk. Catheter-based therapies have gained interest in recent years given the significant bleeding risk associated with systemic thrombolysis. Data are limited to observational studies and small clinical trials with surrogate endpoints, but suggest these therapies may be an effective option with acceptable safety profile. Currently, catheter-based therapies are only recommended at experienced centers for high-risk patients with contraindications to systemic thrombolysis or failed thrombolysis. There have been no randomized trials evaluating embolectomy, and the primary use of this procedure is in patients with shock and a contraindication to thrombolysis or failed thrombolysis.
Approach to Metabolic Alkalosis Simultaneous Acid Base Disorders causing Similar changes in pH best 75 mg endep treatment 7th march bournemouth. Estimate Urinary spot chloride: Metabolic alkalosis may be divided into saline responsive or saline c generic endep 50 mg overnight delivery treatment 001 - b. Respiratory Acidosis and Metabolic Acidosis resistant depending upon whether saline adminis- Cardiopulmonary arrest and acute buy 10 mg endep with amex medications similar to xanax, severe failure of tration can correct the alkalosis generic endep 25mg with amex medications given for adhd. Doing urinary cardiac and respiratory function will lead to mixed chloride estimation can differentiate these two. Patient with persistent vomiting reduction in blood flow to peripheral tissues and – pH = 7. Respiratory Alkalosis and Metabolic Alkalosis Recent Advances This mixed disorder is most often iatrogenic in Continuous intra-arterial blood gas monitoring origin. During periods of Fiberoptic systems are of two categories: (1) acute deterioration in lung function requiring Fluorescent (2) Absorbance. In absorbance-based systems, light is quantified by the equation (10) transmitted to an optical dye phase; the absorbance H+ = 0. The intensity of the returning light signal varies following equation approximates the result of such according to the analyte concentration and this changes relationship is described by Beer-Lambert’s H+ = 0. A 70 Textbook of Pulmonary Medicine capnographic device incorporates one of two types 9. Six steps to acid base analysis clinical analyzers insert a sampling window into the applications J. Carbon dioxide kinetics during anesthesia: cough associated with purulent expectoration, fever pathophysiology and monitoring. Prima of water, electrolyte and acid base A 18-year-old boy was brought to the emergency syndromes, 6th ed; 158-61. He was drowsy but did not have a focal in young and elderly during air and oxygen breathing. The evaluation of the sleep state are referred to as first one third of sleep consists predominantly of screening or simplified studies, e. Hence sleep helps in conservation and recording of various physiological and patho- restoration of energy. By convention, electrodes applied to the left of the head are given odd numbering and the right side even, and they are named C for central, O for occipital, F for frontal, A for auricular. A typical recording channel C3-A2, therefore, means a central, left-sided electrode referenced to the right ear. Electro-oculogram: Electro-oculogram records the eye movement activity during sleep. Also the onset of sleep is heralded by or accompanied by slow, rolling eye movements. Because of this, electrodes placed beside the eyes can measure movement of the eyes. The reference electrode is the auricular electrode on the same side for one electrode and contralateral for the other (e. In this system ventilation and respiratory effort (by strain gauges, the skull is divided into regions by a grid placed induction plethysmography, impedance plethysmo- over it and the distance between various points graphy, and magnetometers) and gas exchange (by (nasion, inion, right and left preauricular points) is oximetry, transcutaneous monitoring or end tidal divided into 10-20 percent intervals. Evaluation of the Respiratory System 75 Additional parameters, which may be included 6. Clinically narcolepsy manifests as ted by the American Sleep Disorders Association abnormal sleep features, overwhelming episodes of report. As per this report the following indications sleep, paroxysmal muscle weakness, cataplexy, sleep have been proposed: paralysis and hypnagogic hallucinations. Follow up polysomnography or a cardiorespi- phenomena that occur predominantly during sleep. Also disruption of sleep-wake schedules and family a satisfactory response after surgical treatment functioning. Also in the in evaluating of resistance syndrome is suspected to allow a patients with sleep behaviors suggestive of distinction to be made between inherent periodic parasomnias that are unusual or atypical because of limb movements and those limb movement the patient’s age at onset; the time, duration or associated with respiratory events. How to reach a diagnosis in patients who sleep-related epilepsy which does not respond to may have the sleep apnoea/hypopnoea syndrome. Rigid bronchoscopy is the transoral passage of rigid Light is generated by an external source and instruments for diagnosis or therapy, facilitated by conducted along the optical fibers to the distal a light source, telescopes, and various specialised object. These bronchoscopes are image back proximally where it is optically enlarged hollow tubes usually of stainless steel with varying for viewing. Adult bronchoscopes are applying suction, instillation of topical anesthetics or approximately 40 cm long with a diameter varying saline, collecting bronchial lavages, and for from 9 to 13. Ventilating bronchoscopes have a proximal end also has an eyepiece with diopter proximal end that contains several ports for light adjustment. The flexible distal tip is maneuvred by guides, telescopes, introduction of instruments, and the proximal control lever. The beveled distal end ensures negotiated into the bronchial tree using this lever atraumatic separation of vocal cords during passage by a combination of flexion, extension, rotation and through the larynx. The foreign body removal, tumor resection, deep newer videobronchoscopes have a computer chip at bronchial wall biopsy, mechanical resection and the tip giving an excellent image resolution, dilatation. Light sources are either and electrocautery probes, balloon dilators, stents, halogen or xenon based. They differ principally in suction catheters and various biopsy and retrieval the intensity of generated light. Contraindications to the procedure are a mouthguard to prevent accidental biting), an unstable cervical spine, severe maxillofacial Endotracheal tube or Tracheostomy tube (using an trauma or deformity, cervical ankylosis and adaptor to facilitate ventilation during the procedure obstructing oral or laryngeal disease. Expertise is extremely important Various types of equipment are available for before embarking onto rigid bronchoscopies. Protected bronchoalveolar lavage catheter enables microbiological sampling of lower respiratory tract flora through bronchoalveolar lavage without any sample contamination by upper airway flora. Flexible biopsy scraper acquires specimens by a scraping action, hence causing less bleeding and a lower incidence of pneumothorax. Bronchoscope through bronchoscope consists of an ultra thin scope (external diameter of 1. Flexible cryoprobes freeze the endobronchial lesion and cause necrosis through crystallization and thrombosis. Endobronchial suture scissors removes suture material involving the endobronchial tree. After the be avoided if possible within 6 weeks of a scopy, the external surface of the scope is cleaned myocardial infarction with moist gauze and water or saline suctioned for • Coagulation profile prior to Transbronchial 10 seconds through the working channel. To stop oral anticoagulants at least 3 days suction valve is then removed and cleaned with a before bronchoscopy if biopsy planned. The • Intravenous access in all patients channel ports and suction ports are also brushed Needless to say, adherence and practice of these clean.
Neuropsychologic out- transient neurologic dysfunction after ascending aortic come after deep hypothermic circulatory arrest in adults 10mg endep with amex medications given to newborns. Hyperglycemia cal dysfunction after deep hypothermic circulatory arrest: a increases cerebral intracellular acidosis during circulatory clinical marker of long-term functional deficit buy 10 mg endep visa medicine 319 pill. Ann Thorac arrest [published erratum appears in Ann Thorac Surg 1993; Surg 1999; 67: 1887−1890 buy 50 mg endep visa treatment plan for depression. Excitatory amino acids as a final brain temperature 75 mg endep with mastercard medications like adderall, metabolism, and function during hypo- common pathway for neurologic disorders. Ann Thorac Surg brain temperature, metabolism, and function during hypo- 2001; 72: 1454−1456. Assessment cerebral metabolism and quantitative electroencephalog- of cerebral blood flow with transcranial Doppler in right raphy after hypothermic circulatory arrest and low-flow brachial artery perfusion patients. Cerebral meta- tive study of brain protection in total aortic arch replace- bolic suppression during hypothermic circulatory arrest in ment: deep hypothermic circulatory arrest with retrograde humans. Markers of cerebral ischemia after cardiac sur- infant heart surgery on late neurodevelopment: the Boston gery. Serum S100 protein: replacement using aortic arch branched grafts with the aid a potential marker for cerebral events during cardiopulmo- of antegrade selective cerebral perfusion. Antegrade serum levels of S-100 after deep hypothermic arrest correlate selective cerebral perfusion in operations on the proximal with duration of circulatory arrest. S100beta oxygenation during paediatric cardiac surgery: identifica- correlates with neurologic complications after aortic opera- tion of vulnerable periods using near infrared spectroscopy. Serum S-100beta monitoring for total arch replacement using selective cere- protein predicts brain injury after hypothermic circulatory bral perfusion. Peripheral markers of temperature with hematocrit level and pH determines of brain damage and blood-brain barrier dysfunction. The use of somatosen- otomy suction on the brain injury marker S100beta after car- sory evoked potentials to determine the optimal degree of diopulmonary bypass. J Thorac Cardiovasc of brain temperatures for safe circulatory arrest during Surg 2000; 119: 132−137. Ann Thorac cerebrospinal fluid is a marker of brain injury after aortic Surg 2002; 74: 2040−2046. Does the Perfusion Via Innominate Artery in Aortic Arch Replacement arterial cannulation site for circulatory arrest influence Without Deep Hypothermic Circulatory Arrest. Determination of size of artery: an alternative site of arterial cannulation for patients aortic emboli and embolic load during coronary artery with extensive aortic and peripheral vascular disease. Axillary artery can- retrograde and selective cerebral perfusion with transcranial nulation: routine use in ascending aorta and aortic arch Doppler. Total aortic arch replacement of cold reperfusion after hypothermic circulatory arrest. Right axillary cannula- mild hypothermia after experimental hypothermic tion in the left thoracotomy for thoracic aortic aneurysm. Effects of pH on thoracoabdominal aneurysm repair under deep hypother- brain energetics after hypothermic circulatory arrest. J Thorac Cardiovasc Surg tion of the left common carotid artery in thoracic aorta oper- 1995; 110: 1649−1657. Sympathoadrenal func- retrograde cerebral perfusion to antegrade cerebral perfu- tion during cardiac operations in infants with the tech- sion and hypothermic circulatory arrest in a chronic porcine nique of surface cooling, limited cardiopulmonary bypass, model. J Card Surg 1994; repair using hypothermic circulatory arrest technique 9: 525−537. J Cardiothorac Vasc Anesth arch replacement using a trifurcated graft and selective 1999; 13: 176−180. Temperature effects of aprotinin on blood product transfusion associ- monitoring during cardiopulmonary bypass–do we under- ated with thoracic aortic surgery requiring deep hypother- cool or overheat the brain? Cerebral protection meth- Anesthesia is maintained with fentanyl (5 µg/kg/h), propo- ods currently used are profound hypothermic circula- fol (5 mg/kg/h), and vecuronium (4 mg/h). However, the choice of cerebral neuroprotective pharmacologic agents are administered. This approach allows us to reach the mia is the method of brain protection used during aortic descending aorta 5 cm distal to the origin of the lef sub- arch operations requiring a circulatory arrest longer than clavian artery. A major roller pump for disease is a risk factor for stroke afer aortic arch surgery systemic perfusion is placed between the venous reser- [7,8]. Care is taken to continue running the main roller ning or magnetic resonance imaging to rule out cerebro pump using a recirculation circuit even when systemic vascular diseases, and to select the site of cerebral circulatory arrest is applied. Before the ascending aorta is cannulated, epiaortic echo scanning and transesophageal echocardiography are routinely performed to assess whether atherosclerotic plaques are present in the ascending aorta or the aor- Pressure line Balloon tic arch. If the ascending aorta is found to be inappropriate for arterial cannulation by epiaortic echo scanning because of the presence of athero- sclerotic debris, the alternative site for arterial cannula- tion is the right axillary artery. Myocardial protection is provided by both antegrade and retrograde blood cardioplegia. The balloons at their tips tip prevents slippage of the cannula when inflated afer are seen in an inflated state. The cannula, because of its flexible metallic support, can be bent manually at the desired angle without causing any luminal compromise. The temperature continues to drop, it toward the patient`s head so that it does not obscure the usually down to 22°C. Then unilateral cerebral perfusion through 18 French for innominate artery perfusion and 14 French the right axillary artery is maintained at a flow rate of for lef common carotid artery perfusion. These measures cause a important to assess whether cerebral perfusion is adequate retrograde flow of blood in the arch vessels and make or not. Selective cerebral perfusion is started Japan) is used to estimate regional cerebral oxygenation. The right radial artery pressure as well as the bilateral catheter tip pressure is adjusted at around 40 mmHg to Separate graft technique regulate the perfusion pressure. In patients with hyper- tension or those with a past history of stroke, the lower There are two different surgical techniques for total arch limit of the safe range of cerebral autoregulation increases replacement: one is the en bloc repair, in which the arch implying that the perfusion pressure should be raised vessels are reconstructed in an island fashion, and the to around 50−70 mmHg by increasing the perfusion other is the separate graf technique. Afer cooling-down to a trolled; and in Marfan patients, pathological portions of rectal temperature of 25°C, axillary perfusion is reduced the aortic arch can be completely resected. Perfusion pressure and flow rate (right radial artery pressure and bilateral catheter tip pressures) perfusion (innominate and lef common carotid artery 2. Near-infrared spectroscopy artery perfusion) is used in selected patients undergoing 4. Jugular venous oxygen saturation hemiarch replacement for acute ascending aortic dissec- 5. Acute ascending aortic dissection Degenerative aneurysm of the aortic arch The separate graf technique described above can also be The details of our recent technique of total arch replace- applied to the patients with acute ascending aortic dissec- ment with an aortic arch branched graf for degenerative tion [12,13]. Our current indications for total arch replace- aneurysm of the aortic arch are depicted in Figure 14. The distal end of the arch graf is mal descending aorta; rupture or massive false lumen of anastomosed to the stump of the descending aorta with a the aortic arch; compromise of arch vessels; coexistent 3-0 polypropylene running suture and Teflon® felt rein- aortic arch aneurysm; and young Marfan patient with- forcement (Figure 14. The surgi- proximal to its fourth limb, and systemic perfusion to the cal technique of the separate graf technique for acute lower half of the body is started from the fourth limb ascending aortic dissection is essentially the same as that of the arch graf (Figure 14.
J Thorac tion and blood flow following graded forebrain ischemia in Cardiovasc Surg 1994; 107: 788–797 cheap endep 10mg medications not to take after gastric bypass. J Thorac Cardiovasc hypothermic circulatory arrest and retrograde cerebral per- Surg 2001; 121: 1107−1121 generic 25mg endep amex medications before surgery. The third limb is then for degenerative aneurysm safe 50 mg endep symptoms in early pregnancy, except that obliteration of the anastomosed to the lef subclavian artery using a 5-0 false lumen is performed generic endep 50mg otc medications list, and a combined elephant trunk polypropylene running suture. The proximal side of the two-stage cannula for venous drainage in the right atrium. The aorta with a 3-0 polypropylene running suture and proximal portion of the aortic repair is performed during Teflon felt reinforcement, the arch graf is unclamped, systemic cooling (Figure 14. The first limb of Once the patient is cooled down to a rectal tempera- the arch graf is then anastomosed to the innominate ture of 25°C, systemic circulation is arrested, the aorta artery with a 5-0 polypropylene running suture (Figure is unclamped, and the incision is extended to the aortic 14. The descending aorta just below the nula is removed, blood perfusion through the cannula is lef subclavian artery is completely transected. The second limb is anastomosed to the lef tially on the descending aorta just 1 cm below the aortic common carotid artery in a similar fashion (Figure 14. Afer the replacement (n = 5), abdominal aortic repair (n = 3), and outer side of the aorta is reinforced with a Teflon felt strip, miscellaneous procedures (n = 17). First, the distal graf series (between 1986 and 1996) comprising 206 patients anastomosis (Figure 14. The oper- logical energy metabolism, and therefore is the most reli- ative technique used in this series was patch angioplasty able method of preventing the ischemic injury to the brain. Two perfusion through the cannula is continued to remove any hundred and sixty four (53%) concomitant procedures remaining air. The true lumen can be distinguished and aortic arch, utilizing circulatory arrest and retrograde from the false lumen when viewed from the aortic arch. Antegrade cerebral per- oped a new perfusion cannula that can be bent manually fusion with cold blood: a 13-year experience. These cannulae can be placed towards the patient’s experimental study of cerebral protection during aortic arch head so that the operative field is not obscured. Selective cerebral simplified the technique by perfusing only two arch ves- perfusion during operation for aneurysm of the aortic arch: sels instead of three, by using one pump head instead of a reassessment. Surgical outcome as carried out in routine cardiac surgery, instead of moni- of aortic arch aneurysms using selective cerebral perfusion. Total arch replace- ment using aortic arch branched grafts with the aid of antegrade selective cerebral perfusion. Improved results In conclusion, with recent improvements in surgical tech- of atherosclerotic arch aneurysm operations with a refined nique and cerebral protection methods, surgical treat- technique. Simple and safe cannulation technique for ante- arch repair and facilitate the time-consuming total arch grade selective cerebral perfusion. Separate grafts or en bloc anastomosis for arch vessels reimplantation to the aortic arch. Hypothermic circula- graft replacement in patients with acute type A aortic tory arrest in operations on the thoracic aorta. J Thorac Cardiovasc Surg 2000; aneurysm and dissection involving the ascending aorta 119: 558−565. The tion, with the risk of cerebral emboli resulting in per- ascending aorta or the femoral artery have been preferred manent neurological dysfunction. Kazui and colleagues as the standard arterial cannulation sites in aortic arch advocated cannulating the arch vessels carefully via the surgery. However, there is some risk of cerebral embo- less atherosclerotic site away from the orifices of the arch lism in cases where these sites are cannulated, because of vessels [9−11]. However, it is much easier to approach, dissect, and directly cannulate the axillary (or brachial) artery at the armpit (Figure 15. Rationale and evolution of our approach It takes only a few minutes to accomplish all procedures to brain protection from exposure to cannulation. Unfortunately, in Japanese patients, particularly small females, the axillary artery is The prevention of cerebral complications remains a too small to accept larger-size cannulae, even in the proxi- critical challenge in total aortic arch replacement, although mal part of the axillary artery just below the clavicle. In a variety of brain protection techniques have emerged in that case, additional cannulation via the femoral artery or the last 10 years [9−18]. Incidences of neurological tic flow through the right axillary artery then prevents Aortic Arch Surgery: Principles, Strategies and Outcomes. If the ascending aorta does lism caused by retrograde femoral artery perfusion might have atherosclerotic changes, as in cases of atheroscle- therefore be prevented. The proximal-to-mid ascending aorta, away from the aneurysm, is generally safe from this point of view. Cerebral embolism caused by selective innominate artery cannulation can also be avoided. In occasional cases requiringflushing out of debris from a severely atherosclerotic descending aorta, femoral artery cannulation is added. Alternatively, when the dura- tion of the distal aortic anastomosis to the descending aorta is prolonged, this femoral artery perfusion is useful for perfusion of the lower half of the body, in particular the spinal cord and the abdominal visceral organs. Ann Thorac Surg artery perfusion using a prosthetic side graf technique 2007; 83: S805−S810. The axillary artery is exposed below the clavicle, and head was packed in ice to prevent a rise in temperature. A further drawback is bleeding from using another balloon-tip cannula has been added, and the anastomosis site. We therefore prefer simple and easy the lowest core temperature was gradually increased to direct cannulation to the axillary artery over the side graf 25−28°C. However, it may not then be possible for the lef an old cerebral infarction, carotid artery disease, or intra- cerebral hemisphere to be perfused sufficiently through the cranial artery disease. We found that 1−2% of patients developed axillary artery thrombosis or brachial Surgical technique nerve palsy. The axillary artery is fragile, so that cannula- tion or closure should be carried out carefully. Also, the nerves run very close to the axillary artery, so that its expo- Exposure, cannulation, and perfusion sure and dissection must also be done with caution. The right axillary artery (or brachial artery) is brain protection during arch surgery in our center since exposed via a 5–7 cm skin incision in the right axilla. A lef 2000 20–22 ventricular venting tube is inserted via the right upper AxA+Asc. Dissection of aortic arch and 2004 branch vessels is minimized to prevent dislodgement and embolization of loose material. If it is difficult the inside using an electric cautery without incision of the to expose the lef subclavian artery at a distance from the aneurysm (Figure 15. By this maneuver, phrenic and median approach, the lef subclavian artery is lef open. The divided end The ascending aorta is cross-clamped, and cardiac arrest is of the descending aorta is mobilized from the surround- induced by retrograde or antegrade cold blood cardiople- ing tissue by a distance of 3–5 cm distally, and the fragile gia.
