Safe aortic arch clamping in patients with patent internal thoracic artery grafts.

In patients who have undergone coronary artery bypass with a left internal thoracic artery graft, clamping the aorta proximal to the left subclavian artery during descending thoracic and thoracoabdominal aortic aneurysm repair can precipitate major cardiac complications. Many centers use hypothermic circulatory arrest to obviate the need for aortic clamping in these cases. Herein, we describe the successful application of an alternative approach to this problem: performing left carotid-subclavian bypass before aneurysm repair. This technique allows aortic cross-clamping proximal to the left subclavian artery, prevents major intraoperative cardiac complications, and avoids cardiopulmonary bypass and hypothermic circulatory arrest.