Case presentation
A 68-year-old male hypertensive patient presented to the emergency
department with acute anterior chest pain and voice hoarseness of recent
onset. His past medical history was remarkable for an emergency
operation 10 years ago for an acute type A aortic dissection which
involved an ascending aorta replacement with a tube graft.
Computed tomography angiography (CTA) revealed a chronic dissecting
aneurysm originating from the distal anastomosis of the previous 32 mm
Dacron graft and extending to the celiac trunk. Maximum diameter was 10
cm for the descending thoracic aorta at the level of T7 (Figure 1).
Additionally, there was a pseudoaneurysm (3 x 5 cm) in the proximal
aortic arch adjacent to the innominate artery (IA) origin penetrated by
a fractured sternal wire (Figure 1C, D). The aortic arch branches were
not dissected, and all abdominal aortic branches were perfused from the
true lumen. Preoperative evaluation included coronary angiography and
transthoracic echocardiography (TTE) which were unremarkable.
A two-stage urgent operation was planned which initially included a left
carotid to left subclavian artery (LSA) bypass with interposition of 8
mm Dacron graft. The next morning the patient was transferred to the
operating room for the definitive operation. To achieve optimal
perfusion monitoring, three arterial lines (bi-radial, left femoral)
were placed, and continuous cerebral monitoring by means of
transcutaneous cerebral oximetry (INVOS™ 5100C Medtronic, MN, USA) was
used. Cardiopulmonary bypass (CPB) was instituted via arterial
cannulation of the right axillary artery through an 8 mm Dacron graft
along with right femoral vein using a long venous cannula. A repeat
median sternotomy was performed, and systemic cooling was started at
26oC. A left ventricular (vent) catheter was inserted
through the right superior pulmonary vein. During cooling, careful
dissection of the previous Dacron graft and both the innominate and left
common carotid arteries (LCCA) was performed, carefully avoiding the
area of the pseudoaneurysm. The innominate vein was ligated and divided
for better exposure of the aortic arch branches. Antegrade cold
crystalloid cardioplegia (Custodiol 25ml/kg) was administered after
cross clamping the ascending aorta on the previous Dacron graft. Once
the target bladder temperature of 26 o C was reached, CPB was arrested.
The distal ascending aorta and aortic arch just proximal to the origin
of the LSA (zone 2) were excised. An island with the origins of IA and
LCCA was created while the origin of LSA was ligated. Unilateral
selective antegrade cerebral perfusion (SACP) was initiated through the
right axillary artery after snaring the IA and LCCA. A soft guide wire
inside a foley catheter was introduced in the true lumen of the
descending thoracic aneurysm. The soft guide wire was then exchanged
with a stiff wire, and the foley catheter was removed. The hybrid stent
– graft system (28 x 150 mm E-vita open plus, Jotec Inc.) was
introduced in an antegrade fashion though the open aortic arch in the
descending thoracic aorta over the stiff guide wire and released with a
pull—back system. The cuff of the hybrid prosthesis was anastomosed to
the distal aortic stump with 3.0 polypropelene suture and externally
reinforced with a Teflon strip. The Dacron free graft of the hybrid
prosthesis was pulled back and the foley catheter was introduced in the
descending aorta and used for lower body perfusion. The IA and LCCA were
implanted into the Dacron graft using the island technique. Systemic
rewarming was initiated and the final Dacron to Dacron anastomosis
performed. CPB was terminated with minimal inotropic support. Total CPB
time was 220 min with 125 min ischaemia time, 15 min circulatory arrest,
65 min lower body arrest, and 105 min of selective antegrade cerebral
perfusion. The patient’s post-operative course was uneventful.
A month after discharge, the patient was admitted for additional
thoracic endovascular aortic repair (TEVAR) down to the celiac trunk
origin with complete remodelling of the dissected aorta (Figure 2D).