Hybrid Treatment of Complex Thoracic Aortic Aneurysm

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Marijan Koprivanac, MD:

The patient is a 83 years old, frail female, on two liters of oxygen at home, with significant medical history of diabetes and obesity. Incidentally, ascending-descending aortic aneurysm is found after a total right knee replacement, complicated by a pulmonary embolism. CTA angiogram showed a proximal descending aortic aneurysm of 6.2 centimeters and ascending aorta of 5.2 centimeters. Arch diameter was 3.5 and relatively normal in zone two. Echo showed normal LV and RV function and size. There are no significant valvular abnormalities. Central cannulation is performed. The right atrium is cannulated, and an extra cannula is placed in the SVC for retrograde brain perfusion. Retrograde cardioplegia cannula is placed. Aorta pulmonary window is dissected. Cross-clamp is applied. Cardiopulmonary bypass is initiated to start cooling. Head vessels are dissected and exposed. The ascending aorta is divided above the sinotubular junction. The lesser curvature and aortic root are mobilized to maximize efficiency and minimize cardiopulmonary bypass exposure.

Extra aortic wall is removed below the sinotubular junction at non-coronary sinus to exclude more aortic tissue. Aortic valve is assessed for significant fenestrations or calcifications. Cross suspension and stitches are placed. The left atrial appendage clip is deployed. Patient is cooled to the level of deep hypothermia. SVC is narrowly supplied, and circulatory arrest is initiated using retrograde perfusion. The distal ascending aorta is transected. The arch is inspected for tears and backflow from the head vessels. The whole arch is mobilized. The decision is made to perform the B-SAFER technique introduced by Dr. Roselli. A 40 by 10 centimeter stent graft is delivered antegrade into the descending aorta under direct vision. Based on tissue quality assessment and arch disease, the device is deployed and positioned in zone one. The main body is sutured to the lesser curvature and pulled downwards to allow a better manipulation of the arch. A five to 10 millimeter hole is cut into the stent graft and dilated with a clamp. A 13 by 2.5 centimeter branch vessel stent graft is delivered directly through the hole, into the left subclavian artery over a wire. To avoid further intimal injury, the device is dilated by using two methods; with a right angle clamp and with a nine-French Pruitt balloon catheter. Retrograde brain perfusion is stopped and antegrade perfusion is started through the nominate and left subclavian arteries. An additional fenestration with a branch stent graft is placed into the left carotid artery. A 10.5 centimeter stent component is deployed with five to 10 millimeters extending into the aortic lumen. A Pruitt balloon catheter is placed and antegrade brain profusion is continued. The aortic stent graft is circumferentially sutured to the aortic wall with a continued horizontal mattress suture and leaving a rim of the aortic wall.

The suture line is continued behind the nominate artery. The redundant aortic tissue is excised. A conventional single branch surgical graft is beveled and sewn to the arch using imbricated vertical mattress sutures in the posterior wall for hemostasis. The transition from the graft to the nominate artery is carefully sutured, re-implanting the innominate artery to the suture line. All three Pruitts are removed. The 10 millimeter branch is connected to the arterial line, and systemic perfusion is initiated slowly. Simultaneously, high power suction is applied to the head vessels and arch. The graft is unclamped and open to the field to start the healing process. Hemostasis is checked and the rewarming of the patient is started. The coaptation of the aortic valve is checked one more time, and the proximal end of the graft is beveled. A rim of supracommissural aortic wall is left and incorporated into the proximal anastomosis to increase overlapped and hemostasis.

Cross clamp is removed and small earring holes are performed. A total of 24 minutes of deep hypothermic circulatory arrest with retrograde and antegrade cerebral perfusion. Patient is extubated on postoperative day number one. Operative day number seven, patient went to the step down unit and discharged to a skilled nurse facility after three weeks. On postoperative day number 40, patient went home from this SNF. The postoperative CT angiogram showed the surgical graft of the ascending aorta, the arch that continues as a frozen elephant trunk to the level of the mid descending aorta. Root size change from 3.8 to 3.3 centimeter. No evidence of complications such as anastomotic and stenosis, endoleak, or pseudoaneurysm formation. Thank you.

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