Surgical Treatment of Acute Aortic Syndrome

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Initial Phases of the Procedure 

The surgeons began by isolating and preparing the right axillary artery. A purse-string suture was placed using 4-0 polypropylene and a size 17 needle, followed by the cannulation of the axillary artery using the Seldinger technique. 

A median sternotomy was performed, exposing the heart and the aorta. Purse-string sutures were prepared for atrio-caval cannulation, retrograde cardioplegia, and left atrial venting. The right atrium was cannulated, and a catheter was placed in the coronary sinus for retrograde cardioplegia. In cases of acute aortic syndrome, retrograde cardioplegia was recommended to prevent injury to the coronary ostia during selective cardioplegia. 

In this case, due to unfavorable anatomy and the fragility of the arterial wall, direct revascularization of the left subclavian artery was not feasible. Therefore, the left axillary artery was isolated to establish an extra-anatomical bypass. At the end of the procedure, the origin of the left subclavian artery was closed. 

An end-to-side anastomosis was performed between an 8 mm vascular graft and the left axillary artery using a continuous 4-0 polypropylene suture and a size 17 needle. The epiaortic vessels were prepared in sequence: the innominate artery, the left common carotid artery, and the left subclavian artery, which was encircled. A 3/8-inch connector was attached to the side branch of the prosthesis for subsequent systemic perfusion. 

Aortic clamping was performed, and cardioplegia was administered. The aorta was opened, and both proximal and distal stumps were prepared. The native aortic valve was removed, and sizing was performed for the Freestyle prosthesis. Sutures were placed for standard stented valve implantation, using 2-0 with pledges. The left and right ostia of the bioprosthesis were trimmed. A test was performed with a hook to check for any paravalvular leaks. 

Coronary ostia were reimplanted, starting with the left, followed by the right, both using 4-0 sutures and a size 17 needle. Once the target temperature of 26 degrees Celsius was reached, systemic circulation was arrested, and the innominate artery and left carotid artery were clamped. Cerebral perfusion was maintained via the right axillary artery cannula at approximately 7 ml per kg per minute. As soon as feasible, selective antegrade perfusion of the left carotid artery was initiated, with monitoring of perfusion pressure and cerebral oximetry. The aortic arch was prepared up to approximately 2 cm from the origin of the left subclavian artery. 

Deployment 

The endovascular portion of the prosthesis was shaped to match the curvature of the descending aorta, ensuring correct orientation of the side branch. The prosthesis was then inserted into the true lumen of the descending aorta. The protective sheath was gradually retracted, allowing the endovascular portion to expand. The collar and guidewire were removed, completing the deployment of the prosthesis. Finally, the delivery handle was removed. 

An anastomosis was performed between the prosthetic collar and the aortic wall using a continuous 3-0 polypropylene suture and a size 22 needle. The authors suggest placing a vacuum vent line between the prosthesis and the aortic wall to maintain a bloodless surgical field. 

Systemic perfusion was then restored antegradely through the side branch of the graft by connecting a 3/8-inch tube. A second continuous reinforcing suture was placed using 4-0 polypropylene. The proximal anastomosis between the vascular portion of the prosthesis  and the aortic stump, including the Freestyle prosthesis, was performed using a continuous 4-0 polypropylene suture and a size 22 needle, incorporating a Teflon felt layer. 

A second continuous reinforcing suture was performed using 4-0 polypropylene. The heart and vascular prosthesis were de-aired, and the aortic clamp was removed. 

Final Debranching

The left carotid artery was connected to branch number eight of the prosthesis using a continuous 5-0 polypropylene suture, followed by deairing. The innominate artery was then connected to branch number 10 with a continuous 4-0 polypropylene suture, followed by de-airing. 

The extra-anatomical bypass between the lateral branch and the left axillary artery was completed through mediastinal tunneling. This anastomosis was performed with a continuous 4-0 polypropylene suture and a size 17 needle.

Unused branches of the prosthesis were double-ligated, cut, and the stumps were closed with a continuous 4-0 polypropylene suture. Flow was checked, and the right axillary cannula was removed. 

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