Discussion
In arch repair, the LSCA is deeply located, which makes it difficult to visualize and therefore, creates technical challenges during surgical repair in some patients. Therefore, several innovations have been designed to facilitate the reconstruction of the LSCA, including direct anastomosis, carotid-LSCA transposition or bypass, left axial extra-anatomic bypass, and ligation without revascularization [1-2]. Direct end-to-end anastomosis is the simplest. However, anastomosis and hemostasis are technically difficult in patients with deep LSCAs. The LSCA easily retracts cranially following its transection. In contrast, an extra-anatomic bypass of the left axial bypass through the left thorax is used to avoid complex LSA anastomosis; however, it requires an additional incision to expose the left axillary artery. This procedure is time-consuming and is accompanied by the risk of brachial plexus injury and wound infection [3]. Furthermore, postoperative adhesion around the bypass in the left thorax can complicate future open surgery via left thoracotomy for the enlarged descending aorta.
Our reconstruction technique provides excellent exposure of the LSCA by pulling the origin of the LSAC caudally, which simplifies the anastomosis. Hemostasis after reconstruction is feasible, as the anastomosis in the anterior wall of the LSCA is easily visualized. The disadvantage of our technique is the extension of total circulatory arrest time which requires almost ten minutes.
The selection of patients for this technique is important, and it is contraindicated in patients with dissected LSCA or LSCA with atherosclerotic plaques, which can be repaired by the left axial extra-anatomic bypass or fenestrated FET techniques [4].