Repair of Saccular Aortic Arch Aneurysm in a Patient With Behcet Disease and Multiple Aortic Aneurysms

A 30-year-old male patient was diagnosed with Behcet disease in January 2020 when he was admitted with abdominal aorta vasculitis.  This resulted in a leaking large abdominal aneurysm that was repaired by the vascular team using a tube graft.  The work up on that admission showed pulmonary embolism in the left lower lobe branches and RV thrombus as well.  There was a saccular aortic arch aneurysm distal to left common carotid artery and the left subclavian artery was not visualized. There was no evidence of dissection or leak. ECHO: EF 33%, RV thrombus protruding into RVOT. He had a smooth postoperative course and was discharged on immunosuppression and anti-coagulation medications. He was seen for regular follow up in CT surgery clinic for his arch aneurysm.

Ten months later the patient was admitted with chest pain. ECG-gated CT ruled out aortic dissection and leak but there was progressive dilatation of the arch aneurysm up to 6 cm over a few months. During his hospital stay, he developed severe chest pain, and another CT was done which showed no changes. We discussed with the vascular team whether stenting was possible, but because of generalized vasculitis, previous AAA repair, and short landing zones, he was not good candidate for that. He remained stable and was prepared for urgent repair through sternotomy.

Technique:
The arterial cannulation used for the CPB was through the right axillary artery (subclavicular incision) and left femoral artery (left groin incision). For the venous line, a double stage cannula was inserted into the right atrium. For cardiac and brain protection, The heart was arrested using intermittent ante- and retro-grade cold blood cardioplegia throughout the procedure in addition to deep hypothermic circulatory arrest with continuous antegrade brain perfusion through the right axillary artery cannula.

After sternotomy, heparanization and cannulation, dissection exposed the ascending aorta, the arch, and its branches. The brachiocephalic trunk and the right common carotid were controlled. We could not find the left subclavian artery. The aneurysm was located distal to the right common carotid artery.

CBP was established. After applying cross clamp to the ascending aorta, the heart was arrested. The arch branches were occluded. More dissection was done to expose the aneurysm. The aneurysm was opened, and the clots were evacuated. The diseased wall was excised. A Hemashield patch was tailored to the arch defect. The defect was closed with the patch using 4/0 proline sutures and then re-enforced with bio-glue. De-airing, weaning and closure were done as routine. The bypass time was 205 min, the crossclamp was 4 min and the circulatory arrest was 69min.

The patient had uneventful postoperative course. He was extubated on day 0 and was discharged on day 9 after adjusting the anticoagulation dose.

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