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Surgery for a Type A Aortic Dissection with Root Tear

Monday, November 17, 2014

This video illustrates the technique used to repair an aortic dissection with a tear involving the aortic root contiguous with the right coronary artery (RCA). In addition to the dissection repair, an aortic root replacement and a jump graft to the RCA are performed.


Thank you for the highly didactic video. Two questions: 1) Along Selective Antegrade Cerebral Perfusion (Right Axillary artery cannulation) you noticed blood in the arch. In which situation are you going to clamp the controlateral CCA so the circle of Willis is fully 'closed' (apart from the left Vertebral artery)? Do you stay on flow of 10ml/kg/min perfusion selectively an 'open' or 'closed' Circle of Willis? 2) Why you choose to anastomose the proximal end of the vein graft to the prosthetic sinus and not more distal on the vascular conduit (just like a usual proximal anastomosis)? Were you aiming for short length of graft and high flow (just like in a BT shunt). Thank you. George Belitsis, Senior Fellow in Cardiothoracic Surgery, Royal Brompton and Harefield NHS Trust, London, UK.
Thank you for your questions, George. Generally speaking, I clamp the common carotid artery, in addition to the innominate artery. Moreover, I will also clamp the left subclavian. Whether I do or not depends on the degree of atherosclerosis of these vessels and the ease of accessibility. My flow rates during ACP are generally around 30-50 cc/kg/min. As for the site of the proximal anastomosis, I chose to originate the graft at the porcine right coronary ostium for convenience more than for any other reason. It also minimizes graft length so that flow is maximized.
Excellent video ! One question: When bypassing the RCA why was the SVG used for the the anastomoses other than bypassing with the RIMA and thus minimizing the risk of restenosis and the poor long term patencey rates of the vein graft , was there a contra - indication of using the ITAs for bypass in this particular patient ?

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