Type A Dissection Repair Using the Florida Sleeve Technique

Introduction
A 56-year-old man status post repair of a descending thoracic aortic aneurysm after type B aortic dissection presented with acute type A dissection. The patient had a long history of drug abuse and disclosed using cocaine two days prior to presentation.

Methods
A median sternotomy was performed. The right subclavian artery was cannulated using the graft technique. The right atrium was cannulated to establish cardiopulmonary bypass. Epiaortic scanning showed significant clot in the area proximal to the innominate artery.

Deep hypothermic circulatory arrest was initiated at 20˚C. The aorta was then opened and significant clot was removed. The innominate artery was clamped. A balloon-tipped catheter was advanced into the left carotid artery and antegrade cerebral perfusion was started. A 26 mm graft was directly anastomosed to the aorta 1 cm proximal to the innominate artery. The graft was clamped and deaired and rewarming begun. Aortotomy was performed 1 cm above the sinotubular junction. The dissection at the noncoronary and right coronary sinuses was repaired with Teflon felt inserted between the intima and adventitia and secured with BioGlue.

Two openings were created on a 38 mm graft to accommodate the coronary arteries. The 38 mm graft was then cut to the height of the sinotubular junction and anastomosed to the ascending aorta in a continuous fashion. Next, the 26 mm graft was anastomosed to the sleeve graft placed over the aortic root. The patient was weaned off cardiopulmonary bypass and the chest was closed in standard fashion. The patient had an uneventful hospital course and was discharged on the fifth postoperative day. Six months later the patient underwent successful extent III thoracoabdominal aneurysm repair. Two-year follow-up echocardiogram demonstrated trace aortic insufficiency.

Conclusion
The Florida sleeve procedure allows for preservation of the native aortic valve and sinuses in appropriately selected patents. Long-term studies are necessary to assess its durability.

Additional Resource
Hess PJ Jr, Klodell CT, Beaver TM, Martin TD. The Florida sleeve: a new technique for aortic root remodeling with preservation of the aortic valve and sinuses. Ann Thorac Surg. 2005;80(2):748-750.