Thoraflex Hybrid Graft Insertion in a Patient With Marfan Syndrome

A 30-year-old man underwent a Bentall procedure (mechanical prosthesis) for aortic root aneurysm and bicuspid aortic valve at the age of 20. Subsequently, at the age of 28, he had a spontaneous type B aortic dissection, which was treated medically. He was followed with serial computed tomography angiography (CTA) and was found to have expansion of the proximal descending thoracic aorta to 4.5 cm, with an expansion of more than 1 cm over one year. Complete replacement of the arch with the Thoraflex Hybrid graft was planned, with extension later by thoracic endovascular aortic repair (TEVAR). 
 
A redo sternotomy was performed, with arterial cannulation via a straight graft to the innominate artery, followed by direct right atrial cannulation. The sequence of cardiopulmonary bypass (CPB) and graft anastomoses was initiated with cooling to 28 degrees Celsius and then completed with unilateral antegrade cerebral perfusion. First, the aortic arch was connected to the graft cuff in Zone 1 while CPB was maintained through the anterior graft limb and rewarming was initiated, together with innominate arterial inflow. Next, the anastomosis of the left subclavian artery to the distal arch graft limb was completed, followed by the anastomosis of the left common carotid to the middle arch graft limb. The anastomosis to the proximal aortic, in this case, was made to the previous Bentall graft. After removing the cross-clamp, myocardial perfusion was started, and finally, the anastomosis of the innominate artery to the proximal arch graft limb was performed, with CPB being discontinued at 37 degrees Celsius.  
 
The patient recovered well. In the opinion of this surgeon, this sequence of CPB and anastomoses utilizes efficient time and temperature management. When the anastomoses are completed, the patient is usually warm. One difficulty can arise during the left subclavian anastomosis because of limited exposure. Occasionally, the author has sewn a separate straight graft to the left subclavian on CPB before circulatory arrest as a preliminary procedure to facilitate the later anastomosis. However, this was unnecessary in this case. 

Murad Hassan, MS1 at McGovern Medical School, Houston, Texas, contributed to this video production.  

References

1. Shih E, Eisenga JB, McCullough KA, DiMaio JM, Roberts CS. An early experience using a hybrid graft for aortic arch dissection. Am J Cardiol 2024; 233: 96-100

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