1.2 Surgical procedure
The patient was transferred immediately to the operating room. During induction of anesthesia, the patient’s blood pressure dropped to 55/35 mmHg. Median sternotomy and pericardiostomy were performed immediately. A massive hematoma was removed, improving the patient’s hemodynamic status. Careful inspection revealed no active bleeding from the aorta. Exploratory laparotomy showed extensive bowel ischemia, recognized by intestinal pallor, absence of peristaltic movement, and loss of pulsation of the main trunk and branches of the SMA. To prevent progression to irreversible bowel damage, SMA-left external iliac artery bypass was performed by application of a saphenous vein graft. After revascularization of the SMA, mesenteric perfusion quickly improved, as evidenced by pulsation of the intestinal arteries and peristalsis. Cardiopulmonary bypass (CPB) was then established by cannulation of the right femoral artery and the superior and inferior vena cava and placement of a left ventricular venting tube via the right upper pulmonary vein. The patient was cooled to 21.9°C, and the dissected ascending aorta was excised. The primary entry tear was resected, and open distal hemiarch replacement was performed. There were no further signs of mesenteric malperfusion during the surgery. The abdomen was closed on postoperative day (POD) 1, and the patient was extubated on POD 2. The postoperative course was uneventful, and CT performed on POD 7 showed an expanded true lumen, opened side branches of the abdominal aorta, and patency of the venous graft. The patient was discharged complication free on POD 20. CT performed 8 months after the surgery revealed a patent venous graft (Figure 2). Twelve months have passed since the surgery, and the patient remains healthy.