One-stage transmediastinal surgical approach for extensive aortic pathology.

"One-stage" transmediastinal replacement of the thoracic aorta provides an alternative treatment to single or multiple stage hybrid procedures for patients with ascending, arch, and descending thoracic aorta aneurysm. The patient is placed on bypass and cooled. During circulatory arrest, after surgical treatment of the aortic valve and root where appropriate, the entire ascending aorta is excised and the transverse arch is opened longitudinally. The heart is retracted cephalad and the left pleural cavity is entered longitudinally. The descending aorta is exposed through the posterior pericardium and opened transversely. After supra-aortic vessel reimplantation, a quadrifurcated Dacron graft is pulled into thorax behind the left lung, towards the hilum, and anastomosed to the descending thoracic aorta in an end-to-end fashion at the level of the transverse aortotomy. This anastomosis effectively seals the descending thoracic aorta. A Dacron patch is used also to close the upper descending aorta. The proximal graft is then sewn to the ascending aorta. The patient is rewarmed and weaned from cardiopulmonary bypass.