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Objectives: The outcome of aortic arch repairs by means of three different approaches between 1990 and January 2000 was reviewed. Methods: In total 39 patients aged 71.5 ^ 6.2 years were operated on. The three different surgical approaches depended on the anatomical positions of the aneurysms and on their proximal or distal extension; a median approach was employed in 23 patients, whereas a left posterolateral approach was used in eight patients. More recently, in eight cases a left antero-lateral approach was applied. All patients underwent open aortic anastomosis without any clamp on or around the aortic arch. During the procedure, the brain was protected by a combination of profound hypothermic circulatory arrest and several techniques of retrograde cerebral perfusion. Results: Permanent cerebral dysfunction occurred in four patients: two in the median approach and two in the left postero-lateral approach. There were two hospital deaths (5.3%) and six late deaths, all of which belonged either to the median group or to the postero-lateral group. The antero-lateral approach did not produce any cerebral dysfunction, early death, or late death. Conclusions: The outcome of aortic arch repairs using profound hypothermic circulatory arrest and variable techniques of retrograde cerebral perfusion, by means of three different approaches, was satisfactory. Of the three approaches, the antero-lateral approach can be employed easily, whether aneurysms extend proximally or distally. q 2001 Elsevier Science B.V. All rights reserved.

Objective: To assess the value of monitoring of regional cerebral oxygen saturation (rSO 2 ) during aortic arch surgery using continuous retrograde cerebral perfusion (CRCP) in conjunction with profound hypothermic circulatory arrest (HCA). Methods: The rSO 2 of 12 consecutive patients was monitored non-invasively using near-infrared spectroscopy (NIRS) and the data were analyzed statistically. Results: The mean duration of HCA with CRCP was 62 ± 14. min. The mean CRCP flow rate was 226 ± 163 ml/min. Surgical outcomes were favorable with only a single hospital death (8.3% ). However, the rSO 2 decreased gradually in all patients during HCA, even combined with CRCP, and fell to 46 ± 8.7% on average. It did not change so greatly before HCA and returned finally to its initial level at the end of re-warming. Only one patient developed a permanent neurologic deficit; this patient showed the greatest decrease of rSO 2 from 56% to 29% after the longest HCA of 88 min. Two parameters, End-rSO 2 (the ratio of post- to pre-HCA rSO 2 ) and Δ-rSO 2 (the rate of decrease from preto post-HCA rSO 2 ) were obtained since the initial values of rSO 2 before surgery differed. There were linear correlations between the CRCP flow rate and each of these two parameters. A multiple regression analysis also revealed a linear equation relating the parameters, which allowed prediction of the safe duration of HCA in different conditions of CRCP and a more favorable adjustment of the CRCP condition in each patient. Conclusions: The study suggests that the combination of HCA and CRCP has a limit of safe duration in spite of its potential usefulness for brain protection, and that rSO 2 monitored by NIRS is useful in testing for adequate brain protection. It is hoped that monitoring of rSO 2 can facilitate prediction of the safe duration of HCA with CRCP and a more favorable adjustment of CRCP.