In the operating room, patients were routinely monitored in terms of electrocardiography, pulse oxygen saturation, cerebral oxygen saturation, central venous pressure, and invasive arterial blood pressure in the left radial artery as well as the left or right femoral artery. Anesthesia was induced by intravenous injection of 0.1 mg/kg midazolam, 0.3 mg/kg etomidate, and 0.7 to 1.0 μg/kg sufentanil, and muscles were relaxed using 0.6 mg/kg rocuronium. After intubation, mechanical ventilation was performed at a tidal volume of 8 to 10 mL/kg and frequency of 10 to 12 times per minute to maintain the end expiratory pressure of carbon dioxide at 30 to 35 mm Hg. Anesthesia was maintained using the following drugs and doses (per kg per hour): cisatracurium, 0.1 to 0.15 mg; sufentanil, 0.7 to 1.0 μg; propofol, 2.0 to 4.0 mg; and dexmedetomidine, 1.0 μg.

Median sternotomy was performed, then heparin (3 mg per kg) was injected intravenously. CPB was established by exposing the axillary artery, then anastomosing it with a graft for artery perfusion. Next, a double-staged cannula (32/42Fr, Medtronic, Minneapolis) was inserted into the right auricular appendage for venous drainage. The bypass circuit was completed with a roll pump (S5, Stockert, Munich, Germany) and membrane oxygenator (BB841, Medtronic). The circuit was primed with Ringer's solution containing sodium acetate, hydroxyethyl starch, and albumin.

The aorta was cross-clamped at a nasopharyngeal temperature of 34°C, and Del Nido cardioplegia was achieved by perfusing the left and right coronary arteries with priming fluid (20 mL per kg). Selective antegrade cerebral perfusion was performed at 5 to 12 mL per minute per kg via the innominate artery when the nasopharyngeal temperature was 25°C and the anal temperature was below 28°C. Total arch replacement combined with stented elephant trunk implantation was performed. During circulatory arrest, left radial artery pressure was maintained at 20 to 30 mm Hg. Perfusion of the lower body was resumed after anastomosis of the graft and descending aorta.

The left common carotid artery was anastomosed with the graft. When mixed venous oxygen saturation exceeded 65%, rewarming began. Then the ascending aorta was anastomosed using an artificial four-branch blood vessel. The aorta cross-clamp was removed. Vasoactive drugs were used as necessary to stabilize circulation.

Sufentanil was administrated after surgery. Sufentanil was stopped before extubation in order to keep the patients conscious.

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