Fig. 2

Schematic drawing depicting the customization of a multi-branched arterial line with 5 inflow branches. One was temporarily clamped to be used only after the distal anastomosis (inflow 5); 3 of the other 4 served for perfusion of the SAVs and 1 for TDA antegrade perfusion. Note that with this system, all lines derived from a single centrifugal pump. Two 8-mm prosthetic tubular grafts were anastomosed in termino-lateral fashion to the right and left subclavian arteries and connected to inflows 1 and 2 of the ECC circuit. The left carotid artery was clamped at its origin to check for good left hemisphere NIRS: then it was ligated and transected, then another 8-mm prosthetic tubular graft was anastomosed in termino-terminal fashion to its distal stump and connected to inflow 3. Under fluoroscopic guide, a Reliant balloon (Medtronic, USA) was driven into TDA percutaneously through a 12 Fr introducer sheath from the left femoral artery: a centimeter-marked pigtail catheter allowed for correct positioning of the balloon at 15 cm from the previously marked left subclavian offspring. A long Revas 18 Fr perfusion cannula (Eurosets, Italy) was positioned right below the balloon through the right femoral artery to allow antegrade perfusion in the TDA. This cannula was then connected to inflow 4 (clamped until the balloon was inflated after cardioplegic arrest)