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I was wondering if 33889/33891 was the right way to go with this one...this is the first one i've had like this. the endograft placement was dictated separately. i'll attach that note in another question. thanks!! PREOPERATIVE DIAGNOSES: 1. A 9-cm aortic arch aneurysm. 2. Need for aortic arch revascularization. POSTOPERATIVE DIAGNOSES: 1. A 9-cm aortic arch aneurysm. 2. Need for aortic arch revascularization. OPERATION PERFORMED: 1. Right-to-left carotid-carotid bypass with 8-mm Dacron and retropharyngeal tunnel. 2. Left carotid-to-left subclavian artery bypass graft with 8-mm Dacron graft. 3. Ligation of proximal left common carotid artery. 4. Ligation of proximal left subclavian artery. ANESTHESIA: General endotracheal anesthesia. Estimated blood loss is 300 mL. IV fluids were 2700 of normal saline and 2 units of packed red blood cells. Urine output was 450 mL. COMPLICATIONS: None apparent. INDICATIONS: This 77-year-old male had been seen by Dr. XXX approximately 2 years ago with an arch aortic aneurysm. He has underlying dementia and confusion and because of the need for likely circ arrest for repair of the aortic arch, Dr. XXX did not feel that the patient was a good open operative candidate. We were consulted for a possible endovascular repair. In reviewing the images, we would need to debranch the aortic arch and reroute for the left common carotid and subclavian arteries. I have recommended a carotid-carotid bypass as well as a left carotid-to-subclavian artery bypass graft. They understood the risks and benefits and wished to proceed. OPERATION: Patient brought to the Hybrid operating room and placed in the reverse Trendelenburg position. After adequate general endotracheal anesthesia was achieved and time-outs performed, the bilateral neck and chest were prepped and draped in a sterile fashion. Cushions had been placed to the heels as well as to the sacrum as well. A supraclavicular incision was made in the left supraclavicular fossa approximately 1 handbreadth proximal to the clavicle. This was carried down through the platysma, anterior scalene fat pad, and through the anterior scalene muscle. The subclavian artery was identified and looped distally with a vessel loop. There was a moderate amount of inflammation in this area felt secondary to the aneurysm. We were ultimately able to get a 0 silk tie proximal on the left subclavian artery, which was proximal to the vertebral artery takeoff. Branches of the thyrocervical trunk were then ligated in order to facilitate exposure. Next, the right common carotid artery was dissected free from the surrounding structures via a lateral neck incision along the anterior border of the sternocleidomastoid. The internal jugular artery is reflected laterally and the common carotid artery looped proximally with an umbilical tape and distally with vessel loop. A retropharyngeal tunnel was then begun, which was posterior to the esophagus and right over the vertebral bodies. This was deepened toward the left carotid artery. Next, the left common carotid artery was exposed in a similar fashion and a retropharyngeal tunnel obtained. The patient was then systemically heparinized with 5000 units of heparin and the right common carotid artery clamped proximally and distally. A arteriotomy was created on the medial aspect and an end-to-side anastomosis constructed with an 8-mm Dacron graft using 6-0 Prolene suture from the heel and the toe. Prior to completion of anastomosis, the collateral graft was clamped and antegrade and retrograde flushing performed. Next, the anastomosis was secured and appeared to be hemostatic. The graft had previously been brought through the retropharyngeal tunnel and was now anastomosed to the distal right common carotid artery in a similar fashion as the proximal anastomosis. Once this was complete, flow was restored to the brain. At this point, the left common carotid artery was looped proximally with a 0 silk tie and a retrojugular tunnel created and the 8-mm Dacron graft passed through the tunnel. A end-to-side anastomosis was created on the lateral aspect of the left common carotid artery with a 6-0 Prolene suture. The graft was then clamped and then the end-to-side anastomosis created to the subclavian artery using 6-0 Prolene suture. Prior to completion of anastomosis, antegrade and retrograde flushing was confirmed. The anastomosis was hemostatic. The 0 silk ties were then used to ligate the left common carotid and the proximal left subclavian artery. At this point, the wounds were inspected for hemostasis and the right common carotid artery incision closed with 3-0 Vicryl suture followed by 4-0 Monocryl and Dermabond. At this point, attention was then turned to the thoracic endovascular graft, which will be dictated separately. I was present throughout the entire portion of the procedure.