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The patient was a 53-year-old individual with no relevant past medical history. Preoperative imaging demonstrated severe aortic valve stenosis without associated aortic regurgitation and dilatation of the ascending aorta to a maximum diameter of 49 mm. In addition, a bovine aortic arch configuration was identified, characterized by a common origin of the brachiocephalic trunk and the left carotid artery.
The procedure was initiated via an upper hemisternotomy, with extension of the sternal incision into the third intercostal space. After opening the pericardium, the ascending aorta and aortic arch were exposed from the root to the distal arch. Cardiopulmonary bypass was established through femoral arterial and venous cannulation.
Antegrade cerebral perfusion was initiated by cannulating the brachiocephalic trunk using a small-caliber arterial cannula. Subsequently, bilateral cerebral perfusion was achieved through cannulation of the left carotid artery using the same type of cannula.
The brachiocephalic trunk, left carotid artery, and the distal aortic arch—specifically zone two, between the carotid and subclavian arteries—were clamped.
An aortotomy was performed, followed by the replacement of the native valve with an On-X mechanical prosthesis. The ascending aorta was then replaced with a vascular graft, with the proximal anastomosis constructed first.
Given the bovine arch anatomy, the common origin of the brachiocephalic trunk and left carotid artery was divided, allowing separate reimplantation of both vessels into the graft.
The distal anastomosis was constructed in zone two of the aortic arch. After completion, the distal clamp was released, thereby restoring systemic circulation to the heart.
The left carotid artery was then implanted onto a side branch of the vascular graft, and its arterial cannula was removed. Subsequently, the brachiocephalic trunk was anastomosed to a second side branch, and its cannula was also removed.
Cardiopulmonary bypass was discontinued, the femoral cannulas were removed, protamine was administered, and careful hemostasis was achieved.
Following confirmation of adequate hemostasis, the sternum was closed, completing the procedure.
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