Dr Ran&B B. Grin@: I would like to begin with a short description of what we think is a vexing technical problem in dealing with aortic arch replacement, in which we do a beveled anastomosis rather than a complete circumferential anastomosis. We see in Fig 1A the situation in an 85-year-old woman, who despite a IO-cm aneurysm, still had a relatively normal aortic valve, which we were able to conserve by putting a graft right at the commissures, restoring the normal aortic diameter. The problem that had been vexing for us was how to get the proper curve of the ascending aorta without kinks. It finally occurred to us that the distance to the descending thoracic aorta was actually less than the distance to the innominate artery, and perhaps a reverse arch would be something that would work. Figure 1B shows how the graft is trimmed: in the opposite direction from what is usual for this sort of procedure. The distal aorta is cut almost circumferentially at a level just beyond the left subclavian, and the head vessels are left on a little tongue of tissue coming up anteriorly. The suturing is begun at the descending thoracic aorta, back beyond the recurrent laryngeal nerve. The ligamentum is divided in order to bring up an island of arch tissue. We then suture the tongue of the graft to this island, bringing the suture line up into the ostia of the vessels: as Dr Crawford mentioned, you want to leave almost no aortic tissue behind. We also think it is important that the suture line be carefully crafted, so that you have graft on one side, and Teflon on the other. In Fig 1C you see the completed anastomosis with what we call the reverse arch. With this technique, we end up without any wrinkles in the graft even in operations in which there is a great big aneurysm to be removed. Dr KoucMos: We heard a lot about hypothermic circulatory arrest and I think the advantages of this technique have been clearly outlined. Do any of you think there is a role for perfusion of the cerebral vasculature in any cases that involve the aortic arch? Is cerebral perfusion ever necessary? Dr E. Stanley Ctuz#i I really don’t know. The original method of taking out the transverse arch and replacing it was a very cumbersome procedure with temporary and permanent bypasses, and separate lines for cardiopumonary bypass. The method that we currently use, in contrast, is so simple, so easy, and produces such good results, that I just can’t be attracted by an alternative with so much equipment to get in the way. That’s my position at the moment. Dr criqbp I would certainly agree. But, we have to remem-