Reoperative Aortic Root and Cabrol Procedure with Aortic Arch and Descending Thoracic Aorta Replacement

A sixty-three-year-old man with a complex history, including a prior mechanical Cabrol procedure and subsequent total aortic arch replacement with frozen elephant trunk, presented to an outside hospital with a fever. CT imaging revealed a graft infection. The patient was transferred for further management, and after a multidisciplinary discussion, the decision was made to pursue graft explanation and reconstruction. 

First, the right axillary artery was exposed for arterial cannulation. A bilateral anterior thoracotomy was then performed. Extensive mediastinal adhesiolysis was required as expected. After heparinization, cardiopulmonary bypass was commenced through the right axillary artery and dual-stage right atrial cannulas. A retrograde cardioplegia cannula was placed, the aortic graft was cross-clamped, and retrograde cardioplegia was administered. Dissection continued distally on the ascending aorta to free the infected graft where purulent material was encountered. 

Next, attention was turned to the ascending aorta and aortic root. The mechanical-valved prosthetic conduit including the Cabrol graft was removed, and circulatory arrest with bilateral cerebral perfusion was initiated. The arch portion of the prosthetic graft was resected, and the left carotid artery was reconstructed using a branched graft followed by initiation of antegrade cerebral perfusion. After dissecting the innominate artery, cerebral perfusion was stopped and the innominate artery was reconstructed using the branched graft. Antegrade cerebral perfusion was then resumed. 

Attention was then turned to the descending aorta. The descending aorta was transected distal to the stent graft, and the stent graft was removed. The aorta was opened longitudinally, the false lumen thrombus was removed, and the distal aorta was fenestrated. A 32 mm sidearm graft was anastomosed to the distal descending thoracic aorta and lower body reperfusion was initiated. Bleeding intercostal vessels were then oversewn. The proximal reconstruction included a bioprosthetic-valved 32 mm prosthetic conduit with a 6 mm prosthetic graft for the Cabrol reconstruction of the coronary arteries. The left and right coronary arteries were anastomosed to opposite ends of the 6mm graft, and a side-to-side anastomosis was performed between the Cabrol and aortic grafts. The valved conduit and ascending aortic grafts were anastomosed, and the branched graft was anastomosed to the ascending aortic graft, which completed the reconstruction.

References

1. Bianco V, Kilic A, Gleason TG, Arnaoutakis GJ, Sultan I. Management of thoracic aortic graft infections. J Card Surg. 2018;33(10):658-665. doi:10.1111/jocs.13792

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