Minimally Invasive Stage I Elephant Trunk and Aortic Valve Repair

Case Presentation

A 70-year-old woman presented with a symptomatic aortic aneurysm and mild-to-moderate central aortic regurgitation. Preoperative CT-C showed enlargement of her ascending and descending aorta and her aortic arch. Her aortic root was not dilated. Transesophageal echocardiogram demonstrated a trileaflet aortic valve with mild-to-moderate central aortic regurgitation and preserved ejection fraction.

Procedure

The patient underwent a “J-type” partial upper sternotomy with extension into the right fourth intercostal space. Her right axillary artery was exposed. A 10 mm graft was anastomosed at this site. Long femoral venous cannulation was accomplished via the right common femoral vein utilizing the Seldinger technique and transesophageal guidance.

Cardiopulmonary bypass was initiated, the aorta was cross-clamped, antegrade Custodial cardioplegia was administered, and a pulmonary artery vent was placed. The proximal aorta was transected and aortic valve repair was accomplished with subcommissural annuloplasty at the left noncoronary commissure. Upon reaching 20^oC, deep hypothermic circulatory arrest was initiated.

The base of the innominate artery was clamped, and antegrade cerebral perfusion was initiated. The innominate, left carotid, and left subclavian arteries were divided. The aortic arch was divided immediately proximal to the origin of the left subclavian artery. A selective antegrade perfusion catheter was advanced into the left carotid artery. The limbs of a 12 x 8 x 8 mm trifurcation graft were anastomosed to the innominate, left carotid, and left subclavian arteries. Upon completion, the main limb of the trifurcation graft was de-aired and clamped, maintaining antegrade cerebral perfusion.

A 24 mm graft was invaginated into the proximal descending thoracic aorta. The distal anastomosis was completed. The proximal aspect of the invaginated graft was recovered, and a graft-to-graft anastomosis was performed with the trifurcation graft. Full systemic blood flow was reinstituted. The graft was then anastomosed at the sinotubular junction. The patient was separated from cardiopulmonary bypass. She has subsequently made a full recovery.

Conclusion

Minimally invasive techniques can be effectively applied to complex cardiac and aortic procedures. The use of a trifurcation graft in total arch replacement allows for early antegrade cerebral perfusion, and it simplifies the visualization and management of anatomic variants.