References 1. Khoynezhad A. Stroke rate after thoracic endovascular aortic repair may not be equal among various aortic pathologies (letter). Ann Thorac Surg 2008;86:2023. 2. Gutsche JT, Cheung AT, McGarvey ML, et al. Risk factors for perioperative stroke after thoracic endovascular aortic repair. Ann Thorac Surg 2007;84:1195–200. 3. Khoynezhad A, Donayre CE, Bui H, Kopchok GE, Walot I, White RA. Risk factors of neurologic deficit after thoracic aortic endografting. Ann Thorac Surg 2007;83:S882–9. 4. Fattori R, Nienaber CA, Rousseau H, et al. Results of endo- vascular repair of the thoracic aorta with the talent thoracic stent graft: the Talent Thoracic Retrospective Registry. J Tho- rac Cardiovasc Surg 2006;132:332–9. 5. Fattori R, Nienaber CA, Rousseau H, et al. Talent Thoracic Retrospective Registry. Results of endovascular repair of the thoracic aorta with the talent thoracic stent graft: the Talent Thoracic Retrospective Registry. J Thorac Cardiovasc Surg 2006;132:332–9. Arterial Shunt for Bilateral Antegrade Cerebral Perfusion To the Editor: I read with great interest the article by De Paulis and colleagues [1] regarding their initial experience with arterial shunt for bilateral antegrade cerebral perfusion. Considering the risk of complications during the placement of the shunt into the arch arteries, this issue requires comment. Axillary cannulation with a concomitant perfusion of the left common carotid artery, initially with a separate roller pump and later through a Y-shaped branch of the arterial line, has already been described and is widely used [2]. The technical require- ments of this method are limited to a “Y”-shaped connector and a perfusion cannula only. After completion of the arch proce- dure, the additional branch of the arterial line can be used even for switching the arterial perfusion from an arch artery to the aortic graft [3]. Nevertheless, there is still a concern about additional manip- ulation on the arch arteries, which is inevitable during place- ment of the perfusion cannula into the contralateral artery, for completion of the bilateral perfusion. The arterial shunt pro- posed by De Paulis and colleagues [1] functionally offers nothing more than a “Y”-shaped branch of the arterial line with the difference being that perfusion flow to the left carotid artery is not drained from the arterial line directly but from the innom- inate artery using an additional shunt. A “Y”-shaped branch of the arterial line for perfusion of the left carotid artery is associ- ated with the necessity of additional manipulation on only one of the arch arteries, but the placement of the arterial shunt is associated with manipulations on the left common carotid artery and on the innominate artery. These manipulations can increase the risk of neurovascular injuries, especially in cases of acute dissection or atherosclerotic changes of the innominate artery, which are not uncommon in aortic arch diseases necessitating surgery. Moreover, there is also an increased risk of cerebral malperfusion if the proximal end of the shunt is placed too deep into the right subclavian or right carotid artery [4]. Therefore, in my opinion, the shunt for bilateral cerebral perfusion, as pro- posed by De Paulis and colleagues [1], does not represent an attractive alternative to the very simple and safe method of bilateral cerebral perfusion using a systemic arterial inflow to an arch artery supplying the brain on one side and additional perfusion of the contralateral artery through the “Y”-shaped branch of the arterial line. Paul Urbanski, MD, PhD Cardiovascular Clinic Bad Neustadt Cardiovascular Surgery Salzburger Leite 1 Bad Neustadt, 97616 Germany e-mail: p.urbanski@herzchirurgie.de References 1. De Paulis R, Salica A, Maselli D, Scaffa R, Bellisario A, Weltert L. Initial experience of an arterial shunt for bilateral ante- grade cerebral perfusion during hypothermic circulatory ar- rest. Ann Thorac Surg 2008;85:624 –7. 2. Mazzola A, Gregorini R, Villani C, Di Eusanio M. Antegrade cere- bral perfusion by axillary artery and left carotid artery inflow at moderate hypothermia. Eur J Cardiovasc Surg 2002;21:930 –1. 3. Urbanski P, Lenos A, Lindemann Y, Weigang E, Zacher M, Diegeler A. Carotid artery cannulation in aortic surgery. J Thorac Cardiovasc Surg 2006;132:1398 – 403. 4. Orihashi K, Sueda T, Okada K, Imai K. Malposition of selective cerebral perfusion catheter is not a rare event. Eur J Cardiovasc Surg 2005;27:644 – 8. Reply To the Editor: We appreciate the interest of Urbanski [1], and we thank him for the time he has spent in reading our report [2]. Although he does not like our alternative method of bilateral cerebral perfusion, the adducted reasons are somehow speculative and deserve some comments. First, we know perfectly well that our approach offers func- tionally “nothing more” than a Y-shaped branch from the arterial line. However, it could also be said that it offers the same advantages of bilateral perfusion without the presence of a cannula in the operative field. Second, it is quite evident that placement of our shunt is associated with manipulation of both the innominate artery and the left carotid artery. However, the same manipulation is nevertheless required in all cases. In fact, because the innomi- nate artery has to be clamped if perfusing the axillary artery or selectively cannulated in the other cases, it is difficult to under- stand how manipulation of the innominate artery can be com- pletely avoided. From our point of view, the level of manipula- tion is the same. Third, when the shunt is inserted in the innominate artery, the balloon is inflated, the artery is snared, and the shunt is pulled out close to the snare at the base of the innominate artery. Flow coming from the axillary artery will keep the shunt away from the right subclavian and right carotid artery making the risk of malperfusion almost impossible. More- over, because flow comes from the axillary artery, both the artery and the shunt can be washed out with blood and potential debris before inserting the shunt in the left carotid artery. As can be easily seen, technical requirements of our method are much simpler because you do not need a Y-shaped line or a second cannula, you simply need a shunt that stays out of your surgical field. Moreover, after completion of the arch procedure you do not need to switch the arterial line because the axillary artery can be used to perfuse the entire body. In summary, although unilateral selective brain perfusion is often a good option in the majority of cases, we think that the use of the shunt offers a valid alternative for those who prefer bilateral brain perfusion and at the same time an unobstructed operative field. 2024 CORRESPONDENCE Ann Thorac Surg 2008;86:2023– 8 © 2008 by The Society of Thoracic Surgeons 0003-4975/08/$34.00 Published by Elsevier Inc MISCELLANEOUS