With the evolution of technology, thoracic endovascular repair (TEVAR) has been implicated in complex aortic pathologies including acute aortic syndrome. In this case, a seventy-seven-year-old man with a history of open abdominal aortic aneurysm repair and hypertension underwent emergent Zone 2 TEVAR for a ruptured type B aortic dissection (TBAD), which covered the left subclavian artery (LSCA). Postoperative computed tomography displayed growth of the aortic arch aneurysm with type IA and/or II endoleak likely from the proximal landing zone or LSCA. A coronary angiogram showed single vessel coronary artery disease. Total arch repair and closure of the endoleak was indicated.
First, the right axillary artery was directly cannulated. After aortic cross-clamping, the left internal mammary artery was anastomosed to the large diagonal branch. At a bladder temperature of 20℃, pump flow through the right axillary artery was reduced to 1,000 cc/min and the innominate artery and left common carotid artery were clamped to establish unilateral antegrade cerebral perfusion (ACP).
Next, a 12 x 8 x 8 mm trifurcated graft was anastomosed to the left common carotid artery and innominate artery, respectively, which established bilateral ACP. The aortic arch was then resected just proximal to the endograft. The proximal, bare metal part of the endograft was removed by cutting polypropylene sutures at the bottom. A 26 mm graft was inserted to the endograft as an elephant trunk and the LSCA was ligated. Distal aortic anastomosis was then performed with felt reinforcement outside where a needle passes through felt, aortic wall, endograft, and elephant trunk. The inverted graft was retrieved and anastomosed at the sinotubular junction. The proximal part of the trifurcated graft was anastomosed to the ascending graft, and systemic perfusion with rewarming was resumed. A separate 8 mm graft was anastomosed to the left axillary artery, which was tunneled through the intercostal space and anastomosed to the first limb of the trifurcated graft.
Total cardiopulmonary bypass time, myocardial ischemic time, and selective ACP time were 239 minutes, 138 minutes, and 103 minutes, respectively. The patient did not receive any blood products. The patient was extubated on the same day as the procedure and discharged home eleven days following surgery. Postoperative computed tomography showed patency of all supra-aortic vessels without any endoleak.
The authors report a successful case of total arch repair with partial removal of endograft in a patient with recent history of emergent TEVAR for ruptured TBAD.
References
- Ohira S, Malekan R, Kai M, Goldberg JB, Spencer PJ, Lansman SL, Spielvogel D. Reoperative Total Arch Repair Using a Trifurcated Graft and Selective Antegrade Cerebral Perfusion. Ann Thorac Surg. 2022 Feb;113(2):569-576.
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