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Marijan Koprivanac, MD:
We are presenting hybrid arch replacement for retrograde type A dissection with high-risk features. A 38 year-old man with history of hypertension and cocaine use presented with one day of chest and back pain. He was hemodynamically stable with a lactate of 1.9 and no signs of malperfusion. CTA was obtained, showing an acute 360 degree retrograde type A aortic dissection. Here we can see the dissection extend from proximal to the innominate artery takeoff, to as far distal as the renal arteries. On the left is a still of the entry tear in the descending thoracic aorta, and on the right is a still displaying the 360 degree nature of the dissection. The patient underwent median sternotomy for treatment of his retrograde type A dissection.
As he was stable, his aortic arch and innominate artery were dissected out, and his aorta was directly cannulated over a guide wire using Seldinger technique. After the wire was introduced, its position was confirmed to be in the true lumen of the descending aorta on TEE. The cannula was then introduced, and its position was again confirmed to be in the true lumen on TEE. The right atrium was cannulated for venous return. The SVC was cannulated for retrograde cerebral perfusion. An indirect retrograde cardioplegia was introduced. Cardiopulmonary bypass was initiated with immediate cooling of the patient. Bypass flow is confirmed on TEE to be predominantly in the true lumen.
The aorta pulmonary window was dissected, and tissue planes were not affected by dissection. The aorta was then cross-clamped and transected. Characteristically for retrograde type A without a tear in the root or ascending aorta, the flap was filled mostly with clot. Direct intergrade cardioplegia was given, even though the heart did arrest with retrograde cardioplegia alone. A dissection flap of about 270 degrees was visible in the aortic root and ascending aorta, and the root was mobilized as needed, preserving the adventitia.
The dissection flap extended into the right coronary and non-coronary sinuses with detachment of the non-coronary commissure. The aortic valve was inspected and found to be tri-leaflet with pliable leaflets and no calcifications or perforations. The medial layer of the non-coronary and right coronary sinuses were reconstructed with a fashioned felt insert running 5-0 proline. Additional pledgetted suture was placed in the middle of the non-coronary sinus due to some redundancy and to improve remodeling.
All three aortic valve commissures were re suspended with pledgetted 4-0 proline. After deep cooling for 30 minutes, the SVC was snared and circulation was arrested. Retrograde cerebral perfusion was then started. Additional hematoma was identified between the intimal flap and aortic adventitia, and was subsequently evacuated. The arch was inspected and no unexpected tears were found. The innominate artery orifice was identified prior to the aorta being trimmed.
Given that the primary tear was in the descending, no new tears were in the arch and there was no dissection in the head vessels, we decided to perform a fenestrated frozen elephant trunk with a stent in the left subclavian artery. This is the B-SAFER technique as described by Dr. Eric Roselli.
Balloon tip pruned catheters were used to start antegrade cerebral perfusion. When antegrade perfusion was started retrograde perfusion was stopped. A 10 centimeter frozen elephant trunk was carefully deployed in the true lumen, with a proximal landing zone in zone two, without obstructing the left carotid. The stent was gently advanced without resistance to avoid introduction of a new entry tear and deployment into a false lumen.
The arch was further mobilized and suture that would be used for fixating the stent was placed on the lesser curvature to prevent stent dislodgement. A fenestration was made in the stent graph with an 11 blade for a 13 millimeter stent to be deployed in the left subclavian. We used a right angle to spread this fenestration and also to grab the guide wire with the subclavian stent to pull it through more easily.
We subsequently spread the subclavian stent to ensure a good seal and prevent stenosis at its orifice. And again using an antegrade-proved catheter, used the balloon to expand the stent more symmetrically at its orifice, before resuming antegrade cerebral perfusion through the subclavian. We then further trimmed the aorta. The frozen elephant trunk was then fixed in place in zone two with a running 4-0 proline suture on an SH needle starting at the lesser curvature and going between the left subclavian artery and left carotid.
The distal anastomosis was then created with a 30 millimeter single branch gel weave tubular graft, using continuous 4-0 proline. The suture line started at the lesser curvature from graft to stent anastomosis, and as it approached the innominate and left carotid artery, transitioned to a graft to aortic anastomosis.
The suture line remained close to the head vessels with the goal of excluding aortic tissue as much as possible. After finishing the distal anastomosis, meticulous de-airing was performed. Circulation was resumed and rewarming was initiated. Hemostasis at the anastomosis was confirmed and the cross clamp was moved as distal as possible.
The proximal end of the graft was beveled, and the supracoronary proximal anastomosis was created. In creating this anastomosis, bites were taken just above the right coronary. After the anastomosis was created, an anterograde needle was placed, de-airing was performed and the cross clamp was removed. The patient was subsequently weaned off of bypass and decannulated, and true lumen flow was once again confirmed on TEE.
To summarize, we performed a type a aortic dissection repair with replacement of the ascending aorta and arch and a branched stented anastomosis frozen elephant trunk repair, or B-SAFER technique, stenting of the left subclavian artery. He also reconstructed the non-coronary and right coronary sinuses and resuspended the AV commissures. Total circulatory arrest time was 36 minutes. Peak lactate level was 6.2. The patient was extubated on post-OP day two, and discharged home on post-OP day eight. CTA obtained four months post-operatively revealed stable aortic dimensions, no endoleak and a patent left subclavian artery stent. There was excellent remodeling of the thoracic aorta with persistent false lumen in the abdominal aorta, as expected. And the patient was asymptomatic, together, constituting an excellent clinical outcome.
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