Decide from the CT scan which segments are more than 5.5cm, and if there is any coronary artery migration beyond the STJ.
Cannulate in the arch – better to cannulate in the anterior part of the arch near the brachiocephalic artery, behind the innominate vein. No need to sling the vein usually.
CP/Vent cannula to be placed in the ascending aorta that will be resected.
Free up the aorta from the pulmonary artery.
If isolated ascending aorta, cool to 34C.
Can put the sucker in the LV through the aortic valve usually. If slower surgery, then can use RSPV vent.
Flow right down to place the clamp.
Once the cardioplegia is given, decompress the LV completely through the root vent before opening the aorta to minimise any blood spillage.
Use the scissors to cut a fold in the aorta, then use the scissors to cut inside – visualise where the right coronary artery is placed, is it inside or outside the STJ? If migrated outside the STJ, then root would have to be changed as well. Cut carefully leaving a rim of 6-7mm above the STJ. Leave the distal segment with a large cuff in case the clamp will have to be repositioned later.
Size the aorta, and prepare the graft – cut it short enough to place it next to the aorta.
Give cardioplegia with hard-tipped cannula.
5-0 prolene double-ended. Line up the mark on the graft against the nadir of the proximal aorta. Place the knot inside, and start suturing on the left side. Set up the graft edge so that it lines up with the aorta for easy placement of the suture. Take even bites in depth and width, and place the sutures. When going up the side, it may be necessary to take in two bites to keep sutures even. Once half-way up the side, bring the suture on the outside, let the assistant hold that end tight. Take a new 5-0 prolene and make a knot on the outside, about 5-mm before the original suture ended. Tie the original suture to the new 5-0 knot. Cut off the short ends, and place the long end on a mosquito rubber shod on the left side.
Take the other end of the suture on the inside of the graft, and start suturing towards yourself, in the same fashion as before. Once all the way up the side, repeat the locking manoeuvre with a new 5-0.
Run on the opposite suture towards yourself and finish the proximal anastomosis.
Give cardioplegia through a medicut needle in the graft and place a clamp distally on the graft to pressurise it, testing the anastomosis.
Adjust the aortic cross-clamp, and cut out the distal portion with a big enough cuff (6-10mm).
Fashion the graft with a bevel so the posterior part is shorter and the anterior longer.
5-0 prolene double-ended with a mosquito rubber-shod on end. Arrange the graft so that the marker on the graft is aligned with the nadir of the distal aorta. Start the suturing on the opposite side 1cm above the nadir, so that the bottom of the anastomosis is clearly visualised during suturing.
Once suturing reaches a similar height on your side, parachute the graft against the aorta with a nerve-hook, tightening everything, and continue with back-hand suturing on your side, until about half-way and lock it with a new 5-0 suture on the outside of the anastomosis.
Start rewarming.
Repeat the same on the opposite side after continuing the original suture line there higher. Complete the anastomosis ensuring no dog-ears.
Place the medicut for hot-shot. Switch to vent and deair.