One-Stage Total or Subtotal Aortic Replacement
Xiao-Peng Hu, MD, Qian Chang, MD, Jun-Ming Zhu, MD,
CARDIOVASCULAR
Cun-Tao Yu, MD, Zhi-Gang Liu, MD, and Li-Zhong Sun, MD
Department of Cardiovascular Surgery, Cardiovascular Institute and FuWai Hospital, Chinese Academy of Medical Sciences and
Peking Union Medical College, Beijing, China
Background. The goal of total aortic resection surgery is
to correct the extensive or multiple sites of aortic pathol-
ogy, which involves the entire length of the vessel. This
study describes our experience in this operation at Fuwai
Cardiovascular Hospital.
Methods. From February 2004 to October 2005, thirteen
patients with Marfan syndrome underwent one-stage total
or subtotal aortic replacement for aortic dissection or aortic
aneurysms. Four patients received subtotal aortic replace-
ment (ascending aorta to the abdominal aorta). Nine pa-
tients underwent total aortic replacement (ascending aorta
to the aortic bifurcation). Operations were performed under
circulatory arrest with profound hypothermia. Patients
were opened with a mid-sternotomy and a thoracoabdomi-
nal incision. Extracorporeal circulation was instituted with
two arterial cannulae and a single venous cannula in the
right atrium. During cooling, the ascending aorta or aortic
root was replaced. At the nasopharyngeal temperature of
T he goal of total aortic resection surgery is to correct
the extensive or multiple sites of aortic pathology,
which involves the entire length of the vessel. Total aortic
resection as a staged operation has been reported by
several authors [1 4], while Massimo and colleagues
[57] and Svensson and colleagues [8] reported on the
one-stage total aortic replacement from the aortic valve
to the bifurcation. These observations confirmed that
total aortic replacement at a single operation may be
possible. This study describes our experience in this
operation at Fuwai Cardiovascular Hospital.
Material and Methods
Patients
Thirteen patients, 10 men and 3 women, whose ages
ranged from 23 to 47 years (mean age, 34.5 years),
underwent one-stage total or subtotal aortic replacement
between February 2004 and October 2005. All 13 patients
were diagnosed with Marfan syndrome based on the
newly revised criteria in 1996 [9]. Eight patients had
chronic Stanford type A dissection, one had acute retro-
grade type A dissection, three had chronic type B dissec-
Accepted for publication March 3, 2006.
Address correspondence to Dr Sun, Department of Cardiovascular Sur-
gery, Cardiovascular Institute and FuWai Hospital, Chinese Academy of
Medical Sciences and Peking Union Medical College, Beijing 100037,
China; e-mail: huxp21@sohu.com.
2006 by The Society of Thoracic Surgeons
Published by Elsevier Inc
20C, the aortic arch was replaced with selective antegrade
cerebral perfusion. After brain reperfusion, staged aortic
occlusions allowed for replacement of descending thoracic
and abdominal aorta. Intercostal, visceral, and renal arteries
were anastomosed to the graft.
Results. There was no operative or early postoperative
death. One case of postoperative complication was noted
for cerebral infarction secondary to embolism. Spinal
neurologic deficits did not occur. At the last follow-up,
ranging from 4 to 24 months postoperatively, all 13
patients were alive and had good functional status.
Conclusions. One-stage total or subtotal aortic replace-
ment for treatment of extensive aortic disease is feasible
with acceptable surgical risks and satisfactory results. It
can eliminate the risk of remnant aortic aneurysm rup-
ture in staged total aortic replacement.
(Ann Thorac Surg 2006;82:5427)
2006 by The Society of Thoracic Surgeons
tion with aortic root aneurysm, and one had multiple
aortic aneurysms (Table 1). Four of 13 patients had
previous Bentall operation. One patient had a Wolff-
Parkinson-White (WPW) syndrome.
In four patients, the aorta was replaced from the
ascending aorta to the abdominal aorta (subtotal aortic
replacement). In the remaining nine patients, the aorta
was replaced from the ascending aorta to the aortic
bifurcation (total aortic replacement). Four patients had
moderate to severe degree of aortic valve insufficiency
secondary to annular dilatation. They received the Ben-
tall operation concomitantly. The one case with the acute
retrograde type A dissection was an emergent procedure.
Informed consent was obtained from all patients. The
study was approved by our Institutional Review Board.
All patients underwent a complete preoperative inves-
tigation. Magnetic resonance imaging (MRI) or enhanced
electron beam computed tomography (EBCT) and echo-
cardiography were performed to obtain complete infor-
mation for selecting the appropriate surgical technique
(Fig 1). Special attention was paid to aortic valve insuffi-
ciency, location of the coronary ostia, and origin of the
carotid-subclavian, visceral, renal, and iliac arteries to
plan graft anastomoses.
Surgical Procedure
Before the operation, general anesthesia was induced
with double lumen endotracheal intubation. Both radial
and femoral arterial blood pressures were monitored
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Ann Thorac Surg HU ET AL 543
2006;82:5427 ONE-STAGE TOTAL OR SUBTOTAL AORTIC REPLACEMENT

Table 1. Clinical Presentation of 13 Patients

No. Sex Age Diagnosis Operation

1 Male 24 Extensive aortic aneurysm (Bentall Subtotal aortic replacement

procedure previously) (ascending to celiac)

CARDIOVASCULAR
2 Male 46 Chronic type A dissection (Bentall Subtotal aortic replacement
procedure previously) (ascending to celiac)
3 Male 30 Acute retrograde type A dissection David Total aortic replacement
4 Male 23 Chronic type A dissection Bentall Total aortic
replacement
5 Male 27 Aortic root aneurysm Chronic Bentall Total aortic
type B dissection replacement
6 Male 47 Chronic type A dissection Total aortic replacement
7 Male 47 Chronic type A dissection (Bentall Total aortic replacement
procedure previously)
8 Female 33 Chronic type A dissection Bentall Total aortic
replacement
9 Female 35 Aortic root aneurysm Chronic David Total aortic replacement
type B dissection
10 Male 41 Aortic root aneurysm Chronic Bentall Total aortic
type B dissection replacement
11 Male 23 ASD Chronic type A dissection ASD repair Total aortic
replacement
12 Female 29 Chronic type A dissection Subtotal aortic replacement
(ascending to celiac)
13 Male 44 Chronic type A dissection (Bentall Subtotal aortic replacement
procedure previously) (ascending to celiac)

ASD atrial septal defect.

throughout. Blood cell saver was used before and after
cardiopulmonary bypass (CPB). An InterGard (InterVas-
cular, La Ciotat, France) aortic arch graft (4 side branches,
diameter 26 3210 8 8 10 mm) was used to
substitute the diseased aorta.
Patients were placed on the operating table in the right
lateral decubitus position, with the lower body slightly
tilted to the left to expose the abdomen and groin
regions. The entire length of the aorta was exposed
through two incisions. A median sternotomy was made
Fig 1. Preoperative magnetic imaging showing an aneurysm involv-
ing the whole length of the aorta.
to expose the aorta from the valve to the arch. Mean-
while, a second surgical team proceeded to make a left
thoracoabdominal incision to expose the aorta from the
arch to the bifurcation. The skin incision was drawn from
between the left scapula and spinal processes in the
fourth intercostal space, then brought downward along
the paramedian abdominal line after crossing the costal
margin and ending at the level of the pubis.
The left chest was entered through the fourth intercos-
tal space. Occasionally, to gain better exposure of the
distal aortic arch and proximal descending aorta, the
fourth rib was cut. Once the costal margin was inter-
rupted, the left hemidiaphragm was circumferentially
incised along its parietal insertion. Then the peritoneal
sac was detached from the abdominal wall; the abdomi-
nal viscera were moved to the right, and the thoracoab-
dominal aorta was completely exposed.
Extracorporeal circulation was instituted with two ar-
terial return cannulae in the ascending aorta (first four
cases used the right axillary artery) and in the left iliac
artery. Venous drainage was effectuated with a single
cannula into the right atrium (10 cases) or from the left
iliac vein advancing to the right atrium (first 3 cases). The
left heart was decompressed through the right superior
pulmonary vein.
Bypass and cooling were started after opening the
patient. During cooling time, the ascending aorta (prox-
imal to the arterial cannula) was cross-clamped and the
heart was stopped with the injection of a cold blood
cardioplegic solution. In our most recent patient, the
myocardium was cooled down with the whole body and
 544 HU ET AL
ONE-STAGE TOTAL OR SUBTOTAL AORTIC REPLACEMENT
no cardioplegic solution was used. Before the ascending
aortic replacement, a Bentall or David operation was
performed if indicated.
When the nasopharyngeal temperature was lowered to
20C, the upper thoracic aorta, and the arch vessels were
CARDIOVASCULAR
cross-clamped. Then upper body circulation was stopped
and selective antegrade cerebral perfusion began at a
flow rate of 5 to 10 mL kg1 minute1 from the right
axillary arterial cannula or by direct cannulation into the
innominate artery. The ascending aortic incision was
continued to the beginning of the descending aorta,
taking care to avoid injury to the left recurrent laryngeal
nerve. The aortic arch was reconstructed by anastomos-
ing the carotid-subclavian orifices in a single button to
the side of the graft.
Upon completion of this anastomosis, the clamp of the
carotid trunks was removed and the graft was allowed to
fill with blood. After evacuating the air, the graft was
cross-clamped distally at the left subclavian artery, and
the upper body was then perfused through the right
axillary arterial cannula or an arterial cannula inserted
into a 10 mm side branch attached to the graft.
Thereafter, the patient was rotated to the right. The
lower thoracic aorta (at the diaphragm) was cross-
clamped. The incision of the thoracic aorta continued
distally. After removing intimal flaps, the first five inter-
costal orifices were sutured in the lumen of the aorta. The
intercostal orifices from the sixth to the twelfth, which are
considered a vital blood supply of the spinal cord, were
directed into an approximately 2 cm diameter arterial
tube and then anastomosed to an 8 mm side branch
attached to the graft.
The graft clamp was removed from the postsubclavian
area and was placed under this anastomosis, allowing
spinal cord perfusion to be resumed. The clamp of the
lower thoracic aorta was released and placed on the iliac
arterial cannula, thus producing abdominal ischemia.
The incision of the thoracic aorta continued downward to
the abdominal aneurysm.
Finally, the distal anastomosis was accomplished. Usu-
ally, orifices of celiac, superior mesenteric, and right
renal arteries were joined at a single button anastomos-
ing to the distal main graft. The left renal, inferior
mesenteric, and bilateral iliac arteries were connected to
the branches of the graft, respectively. In four subtotal
aortic replacement cases, whose abdominal aorta was
normal, the graft was directly anastomosed at the level of
the celiac artery distally. The clamp of the iliac arterial
cannula was released slowly and air was evacuated from
the graft. When all anastomoses were completed, total
circulation was reestablished, and rewarming was started
(Fig 2; 3).
Cardiac activity generally resumed between 30C and
34C spontaneously or by defibrillation, and at 37C the
cardiopulmonary bypass was discontinued. After hepa-
rin neutralization, coagulation factors were restored by
administering fresh blood, platelets, plasma, and fibrin-
ogen as needed. While on the operating table and in the
intensive care unit, patients were wrapped in a heated
blanket to prevent hypothermia and bleeding.
Ann Thorac Surg
2006;82:5427
Fig 2. The photo shows the graft after all anastomoses were com-
pleted in total aortic replacement.
Follow-Up
The EBCT and echocardiography were performed before
discharge, three months after surgery, and then annually
to evaluate condition of the graft. Follow-up ranged from
4 to 24 months (mean, 14 months). All 13 patients were
alive and had good functional status.
Results
Of the 13 patients, there was no operative or early
postoperative death. The CPB time ranged from 170 to
375 minutes (mean, 276 minutes), the myocardial isch-
emic time ranged from 90 to 235 minutes (mean, 172
minutes), and the selective cerebral perfusion time under
profound hypothermia ranged from 8 to 53 minutes
(mean, 25 minutes).
Ten patients were extubated between first and fourth
postoperative days. One patient had a right hemiparesis
due to embolism after operation. Another two patients
had pulmonary insufficiency and secondary pulmonary
infection. These three patients underwent tracheotomy.
Two patients had chylothorax. Four patients were re-
opened because of bleeding. One patient underwent
lienectomy because of nontraumatic rupture of the
spleen postoperatively. The patient with WPW syndrome
received radio-frequency ablation because of recurrent
supraventricular tachycardia after operation. No spinal
neurologic deficits were observed. All 13 patients were
discharged from the hospital between 14 and 50 postop-
erative days.
Comment
According to Crawford and colleagues [13], more than
half of patients with aortic dissection and Marfan syn-
drome had involvement of multiple aortic segments.
Their long-term studies of surgically treated patients
indicated that residual aneurysm was a frequent cause of
late death. They concluded that, in patients with aneu-
Ann Thorac Surg
2006;82:5427
Fig 3. Schematic drawing of all anastomoses in total aortic
replacement.
rysm, all involved segments larger than 5 cm in external
diameter should be removed. The ideal treatment for
disease involving the whole aorta, therefore, should be
complete resection and replacement of the entire dis-
eased aorta.
Crawfords team performed total aortic replacement in
a staged approach. Borst and colleagues [4] developed
the elephant trunk technique to facilitate extended and
total replacement in a staged operation. Most patients
with extensive aneurysms of the aorta can be treated by
a two-stage elephant trunk procedure with a relatively
low operative risk. But several deaths occurred during
the interval between staged operations due to rupture of
residual aneurysms, refusal of second operation, or de-
terioration of general conditions [1, 2]. Thus, in some
high-risk patients, the one-stage total aortic replacement
should be considered.
Massimo and colleagues [7] reported simultaneous
aortic replacement from the aortic valve to the bifurca-
tion in 34 patients with a 30-day mortality of 14.7%. These
observations confirmed that total aortic replacement may
be appropriate in selected patients.
One-stage total aortic replacement prevents loss of
patients during the interval between staged operations
and avoids the physical suffering of a second operation.
Moreover, it is more economical than a staged operation.
This is very important in poor patients.
The one-stage total aortic replacement is the most
complex operation in aortic surgery. To minimize circu-
HU ET AL 545
ONE-STAGE TOTAL OR SUBTOTAL AORTIC REPLACEMENT
latory arrest time and ischemic time of the brain, spinal
cord, and viscera are key points for success of the
operation.
Surgery on the aortic root could be completed during
cooling and rewarming time. When reconstructing the
CARDIOVASCULAR
carotid-subclavian, intercostal, and visceral arteries, the
technical principle is to include as many vascular orifices
into a single anastomosis as possible. Using these meth-
ods, the CPB and operating times were sensibly reduced.
The extracorporeal circulation, with double arterial re-
turn cannulae, was an effective method in reducing
cooling and rewarming time by allowing early resump-
tion of cerebral, spinal, and visceral perfusion.
Cerebral protection performed with profound hypo-
thermia and selective antegrade cerebral perfusion has
proved completely effective by the absence of permanent
central neurologic deficits except for cerebral infarction
secondary to embolism in one patient. The embolism was
presumedly due to the inadequate evacuation of the air
during the operation. The carotid occlusion time ranging
from 8 to 53 minutes proved to be safe.
Spinal and visceral protection was ensured by pro-
found hypothermia during circulatory interruption and
early resumption of perfusion. With a staged descending
aortic occlusion technique, the ischemic time of spinal
cord and viscera were reduced. No visceral failure and
paraplegia arose in our series.
Myocardial protection was effective for arrest times of
up to 235 minutes. The protection was provided by
profound hypothermia and possibly with a single dose of
crystalloid injected at the moment of aortic cross-
clamping. After the patient was weaned from bypass,
cardiac function proved to be sufficient in sustaining
circulation without mechanical assistance.
Prolonged respiratory assistance and positive end-
expiratory pressure ventilation were required in three
patients due to postoperative pulmonary insufficiency.
This complication was attributed to intraoperative pul-
monary handling, unilateral lung ventilation, and injury
caused by CPB.
Postoperative bleeding caused four patients to return
to the operating room. Coagulation disturbance was
attributed to the impairment of liver, endothelial and
platelet dysfunction after deep hypothermia and pro-
longed extracorporeal circulation. To help bring bleeding
under control, coagulation factors were administered at
the moment of the weaning off of the CPB. Keeping
patients warm was very important as well.
In conclusion, one-stage total or subtotal aortic re-
placement prevents loss of patients during the interval
between staged operations, allows for better early results,
and assures a favorable long-term survival. One-stage
replacement of the entire aorta is feasible with acceptable
surgical risks.
References
1. Crawford ES, Stowe CL, Crawford JL, Titus JL, Weilbaecher
DG. Aortic arch aneurysm. A sentinel of extensive aortic
 546 HU ET AL
ONE-STAGE TOTAL OR SUBTOTAL AORTIC REPLACEMENT
disease requiring subtotal and total aortic replacement. Ann
Surg 1984;199:74252.
2. Crawford ES, Crawford JL, Stowe CL, Hazim JS. Total aortic
replacement for chronic aortic dissection occurring in pa-
tients with and without Marfans syndrome. Ann Surg 1984;
199:358 61.
CARDIOVASCULAR
3. Crawford ES, Coselli JS, Svensson LG, Safi HJ, Hess KR.
Diffuse aneurysmal disease (chronic aortic dissection,
Marfan, and mega aorta syndromes) and multiple aneurysm.
Treatment by subtotal and total aortic replacement empha-
sizing the elephant trunk operation. Ann Surg 1990;211:521
37.
4. Borst HG, Walterbusch G, Schaps D. Extensive aortic replace-
ment using elephant trunk prosthesis. Thorac Cardiovasc
Surg 1983;31:37 40.
5. Massimo CG, Poma AG, Viligiardi RR, Duranti A, Colucci M,
Favi PP. Simultaneous total aortic replacement from arch to
INVITED COMMENTARY
Although the overall results are excellent for those
patients who have Marfan syndrome with a 99.3%
survival rate after surgery, and an 82% 10-year survival
rate in our experience, the question of how to best treat
that subset of Marfan patients with chronic aortic
dissection remains a quandary. Indeed, the 5-year
survival of patients who present with both Marfan
syndrome and chronic aortic dissection is a sobering
50%, mainly as a result of ruptures, re-dissection,
complications of surgery and reoperations as docu-
mented in separate studies by Gott and colleagues [1],
Smith and colleagues [2] and Svensson and colleagues
[3]. For elective cases of the Marfan chronic aortic
dissection subset, we recommend doing a two-stage
elephant trunk procedure. This approach occurs most
often for reoperations in patients who have had previ-
ous acute dissection repairs. The other strategies in-
clude the clam shell incision for patients with aneu-
rysms limited to the chest (ie, usually proximal
descending aorta with a leak or rupture); combined
mediastinal and left thoracotomy incision repairs for
patients who need the aorta repaired to the celiac
artery (ie, for more extensive aneurysms of the de-
scending aorta with leak or rupture of a large aneu-
rysm); a thoracoabdominal incision with right subcla-
vian arterial inflow with hypothermic arrest in
symptomatic patients who require repair from just
above the sinotubular ridge, or after previous compos-
ite valve graft insertion, to the aortic bifurcation; and
the rather uncommon approach of a combined medi-
astinal and thoracoabdominal incision for symptomatic
patients with extensive large aneurysms (ie, typically
those who have both cardiac disease and thoracoab-
dominal components that are symptomatic and requir-
ing immediate repair). It should be noted that for
chronic dissection we avoid doing endovascular stent-
ing procedures, particularly because Marfan patients
are young.
In their article, Hu and colleagues [4] advocate
total or subtotal replacement as the primary pro- visceral arteries in patients with Marfan syndrome and
cedure for these patients because of the high mortality
rates associated with staged procedures. Although we
2006 by The Society of Thoracic Surgeons
Published by Elsevier Inc
Ann Thorac Surg
2006;82:5427
bifurcation: experience with six cases. Texas Heart Inst J
1986;13:14751.
6. Massimo CG, Presenti LF, Favi PP, Crisci C, Cruz Guadron
EA. Simultaneous total aortic replacement from valve to
bifurcation: experience with 21 cases. Ann Thorac Surg 1993;
56:1100 6.
7. Massimo CG, Perna AM, Cruz Quadron EA, Artounian RV.
Extended and total simultaneous aortic replacement: latest
technical modifications and improved results with thirty-four
patients. J Card Surg 1997;12:2619.
8. Svensson LG, Shahian DM, Davis FG, et al. Replacement of
entire aorta from aortic valve to bifurcation during one
operation. Ann Thorac Surg 1994;58:1164 6.
9. De Paepe A , Devereux RB , Dietz HC , Hennekam RC, Pyeritz
RE. Revised diagnostic criteria for the Marfan syndrome.
Am J Med Genet 1996;62:41726.
have reported our 30-day survival rate for first stage
procedures as 98%, a number of patients did not
survive to have the second stage procedure [5], as also
documented by Safi and colleagues [6] and Schepens
and colleagues [7]. Having been alerted to this problem
and applying modifications of our operative technique,
such as avoiding prophylactic elephant trunk proce-
dures (ie, only about 6% required a second-stage
procedure) and earlier use of stenting after surgery, we
were gratified in our most recent study that 85% of our
patients are alive 42 months after surgery. In compar-
ison, our operative mortality rate for the combined
mediastinal and type I or II thoracoabdominal aneu-
rysm repairs has been 16% with a considerably re-
duced long-term survival.
Although Hu and colleagues [4] describe excellent
results during a 20-month period while performing
this combined approach on 13 patients, described by
us [8] and Massimo and colleagues [9], it should be
noted that, as in the case of the Massimo and col-
leagues article [9], total and subtotal does not al-
ways seem to mean that the entire aorta or even the
entire thoracic aorta was replaced during one opera-
tion, which is somewhat misleading. Indeed, 4 patients
were replaced from the ascending aorta to the dia-
phragm (ie, the abdominal aorta), and 4 patients had
previously undergone Bentall procedures, and if the
descending aorta was the symptomatic section, which
is not reported in the article, then the patients may
have well been candidates for less risky operations.
Another caveat is that Hu and colleagues [4] advocate
leaving an en-bloc Carrel patch behind for the aortic
arch vessels or visceral arteries anastomoses in Marfan
patients with aortic dissection, although this is well
documented to substantially increase the risk that a
large number of these patients will require reoperation
for patch ruptures or dilatations. Thus we prefer to do
the elephant trunk stage procedure with branch grafts
to the greater arch vessels and branch grafts to the
chronic aortic dissection. Therefore we only advocate
replacing the entire aorta in a single operation in
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