eComment: carotid cannulation.

Fig. 1. Picture showing the position of four cannulae to achieve a complete antegrade perfusion of epiaortic vessels and peripheral organs. ration was restored and good urine output confirmed a good general perfusion. The patient was cooled down to 18 8C and the operation was then completed in the usual fashion. Complete aortic arch reconstruction with elephant trunk and reimplantation of epiaortic vessels was performed using a 26 mm straight Dacron tube with an external 10 mm branch. Valve sparing aortic root reconstruction was then performed by means of a 28 m straight Dacron tube according to the David procedure. The patient recovered uneventfully from the operation and was discharged home after 15 days. Cerebral malperfusion during CPB is a potentially dramatic situation which can be easily misunderstood if double radial artery wave and cerebral saturation are not monitored. Such a complication is related to the extent of the intimal flap and seems to be increased by the retrograde flow into the thoracic aorta following femoral artery cannulation w1, 2x despite, on the other hand, some studies having confirmed the safety of femoral artery approach w3x. To minimize the risk of malperfusion, axillary artery cannulation which avoids retrograde flow in the dissected aorta, has been proposed as first choice site of arterial cannulation w2, 4x. Alternative sites of cannulation, such as carotid artery, have also been proposed for selected patients w5x. In this case we were not able to achieve satisfactory perfusion neither using axillary cannulation (our first choice) nor using femoral approach. Fortunately, the use of this innovative method allowed us to uneventfully cool the patient down to deep hypothermia and complete the procedure in circulatory arrest as planned, thus solving the problems of malperfusion. We were inspired to such a technique by a paper by Neri et al. w6x who reported the use of an endotracheal tube as a 'modified' cannula to obtain an endo-clamping effect and to achieve cerebral perfusion during descending thoracic aorta surgery. We modified his technique to obtain physiological antegrade perfusion and easy systemic cooling. A similar concept using a new cannula and mild hypothermia was also recently reported by Bakhtiary et al. w7x. In this patient we were able to achieve a full flow with adequate perfusion of full body, nevertheless, we still decided for deep hypothermia for a comfortable distal end anastomosis. Following this successful case, however, we have employed the same …