Surgical Technique
​The patient is positioned with a sandbag under the left shoulder and head turned towards the right side. The upper end of the sternal incision is extended cranially to the left side of the neck over the sternocleidomastoid muscle. With the neck turned to right side, this extension is almost in line with median sternal incision. The sternal head of the sternocleidomastoid is divided from its origin (Figure 1B) enabling the exposure of the left common carotid artery (LCCA) and the LSA. The aorta is then pulled caudally and the supra-aortic arch vessels are dissected and looped. When the desired body temperature is reached, the hybrid prosthesis is deployed in zone 2 and the supra-aortic arch vessels are connected to the hybrid prosthesis (Figure 1 C, D, E). ​After achieving haemostasis, the sternal head of the sternocleidomastoid muscle is reattached using absorbable sutures and chest closed in the usual manner.
When required, the following additional manoeuvres can be used to increase the exposure of LSA. (i) ​Looping, Ligation and division of the innominate vein (Figure 1A) (ii) When the LCCA is used for arterial inflow, both the incisions can be connected (Figure 1B) and (iii) during the antegrade cerebral perfusion, the cross-clamp on the LCCA can be applied in the neck to avoid any paraphernalia in the operative field (Video 1).