Open Hybrid Treatment of Complex Type A Aortic Dissection

Podcast Transcript

Announcer:

Welcome to Cleveland Clinic's Cardiac Consult, brought to you by the Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute at Cleveland Clinic.

Marijan Koprivanac, MD:

This is a case of a 60-year-old patient with a complex acute type A aortic dissection who underwent an open hybrid repair. The patient presented to an outside hospital after loss of consciousness with left-sided chest pain in a hemodynamically stable condition, but with elevated lactate levels. CT angiography revealed acute type A aortic dissection involving brachiocephalic trunk, right common carotid, and extending all the way to iliac arteries.

Right common carotid was occluded, and occlusion appeared to be fixed at both proximal and mid-neck levels. Aorta was directly cannulated over a guidewire using Seldinger technique under TEE guidance to confirm the correct position of a guidewire and aortic cannula. Flow was once again confirmed to be in true lumen on TEE. Right atrium was cannulated for venous return, and additional cannula was placed in SVC to enable retrograde perfusion. Aorta was then cross-clamped, transected, and trimmed to the level of sinotubular junction.

An extensive dissection flap of almost 360 degrees was visible in aortic root and ascending. Aortic valve leaflets were inspected for significant calcifications or perforations, as well as remaining root structures for any intimal tears, and the decision was made to repair the root. Medial layer of non-coronary and right coronary sinus was reconstructed using a Teflon Pledget. The patient was cooled to the level of deep hypothermia. The circulation was arrested, cross-clamp released, and retrograde perfusion started.

Aortic arch was inspected and additional intimal tears were found. The aortic tissue was noted to be very friable, and the decision was made to perform a B-SAFER procedure introduced by Dr. Roselli. We can see a diminished blood flow from innominate artery, which was concerning as patient had fixed obstruction on right common carotid as well as neurological symptoms at presentation. Frozen elephant trunk was carefully deployed in true lumen with proximal landing zone in zone one. Two holes were made in stent graft for stents to be deployed in left subclavian and left common carotid. Stents were gently advanced over a guidewire to avoid further intimal injury. Pruitt catheters were placed in stents, dilated, and anti-grade cerebral perfusion started.

Brachiocephalic trunk was transected and debranched. Frozen elephant trunk was fixed in place using a running Prolene suture, taking bigger bites of aorta and smaller bites of stent graft to prevent stent protrusion. The distal anastomosis was created with 30-millimeter, single-branched tubular graft using continuous 4-0 Prolene suture. Graft was cannulated and RCP started again simultaneously with systemic perfusion to de-air aortic arch and the head vessels.

Due to patient's age, neurological symptoms at presentation, preoperative CT scan, and to the fact that there was no flow coming from right common carotid but only from right subclavian, a decision was made to trim the innominate up to the level of bifurcation and placed in additional stent into the right common carotid. After the stent was deployed, a copious blood flow was immediately noted. Right common carotid and right subclavian were re-implanted, taking previously placed stent into the bite to prevent stent migration. Before finishing the suture line, meticulous de-airing was allowed and re-warming of the patient was started.

The proximal end of graft was beveled and AV commissures were re-implanted in a standard fashion. The AV cusp coaptation was checked once more. The proximal anastomosis was created, taking big supra-commissural bites of aorta. A rim of native supra-commissural aortic tissue was left and incorporated into the proximal anastomosis to increase overlap and improve hemostasis.

After completion, no significant bleeding was noted and the patient was successfully weaned off bypass and decannulated. The circulatory arrest time was 32 minutes and peak lactate level was 6.2. The patient was extubated on first post-operative day and discharged home two weeks after surgery. Post-operative CT scan revealed excellent results, with a small residual dissection in left subclavian, and the patient got a carotid-subclavian bypass, an additional TAVR procedure, six months after initial surgery due to arm symptoms.

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