Hybrid Aortic Type I Dissection Repair

<p>In this video, the authors show a two-stage hybrid treatment strategy for DeBakey type I aortic dissection. The patient was a 70-year-old man who arrived from another institution with a diagnosis of chronic aortic dissection type I of the DeBakey classification.<br></p><p>The computed tomography (CT) scan showed an aortic wall hematoma in the ascending aorta and aortic arch with an intimal flap that reached both femoral arteries, with no compromise of the mesenteric artery or celiac trunk. The renal arteries were affected by the dissection but without flow alterations or renal failure.</p><p>The first stage of this hybrid strategy was the ascending aorta and arch replacement, using axillary cannulation for unilateral cerebral perfusion. After sternotomy was performed, the authors found firm adhesions due to the chronicity of the aortic syndrome that made surgical dissection of the ascending aorta and arch really demanding. After supra-aortic vessels were identified and individualized, cross-clamp of the aorta was achieved and the ascending aorta incised. A huge chronic wall hematoma was found. The ascending aorta aneurysm was resected and the aortic root was prepared for proximal suprasinus aortic anastomosis and aortic valve resuspension.</p><p>When the patient’s body temperature reached 25°C (moderate hypothermia), the supra-aortic vessels were clamped, aortic cross-clamp was removed, and distal aorta circulatory arrest with anterograde unilateral cerebral perfusion was begun. At this moment, the authors continued with aortic arch resection, brachiocephalic trunk and left carotid artery transection, and fenestration of the distal intimal dissection flap. A four-branched graft was prepared and invaginated for arch replacement with an elephant trunk technique. The graft was placed into the descending aorta and the distal anastomosis was done with 4-0 polypropylene continuous suture. The graft was then retracted backwards and the authors used one of the branches to connect the arterial line, allowing the distal aorta perfusion through the graft, with selective clamping of the other branches.</p><p>The authors’ next step was the left carotid artery anastomosis to the second branch of the prosthesis. After this, they decided to complete the proximal aortic anastomosis and thus they were able to reperfuse the coronary arteries and reduce cardiac ischemic time. Afterwards, the brachiocephalic trunk was anastomosed to the first branch of the graft. The left subclavian artery was left in the distal native aorta, and the authors decided not to reimplant it in the prosthesis due to the technical difficulties given by the deep anatomical disposition of it and in order to reduce surgery time. To ensure that there would not be ischemic complications of the left arm, the authors measured the blood pressure in the left radial artery and compared it to the blood pressure in the femoral artery, and they were similar. There were no ischemic complications of the left arm in the postoperative period.</p><p>The patient’s postoperative course required two days in the intensive care unit, blood transfusions, and inotropic support in the first hours. There were no postoperative major complications, and the patient was discharged on the seventh day after the procedure.</p><p>The second stage was carried out three months after the first surgery at the same institution. A thoracic endovascular graft was placed in the distal elephant trunk and descending aorta, excluding the dissection flap. Also, a plug Amplatzer was placed in the left subclavian artery ostium. The postoperative course was uneventful. There were no endoleaks or ischemic complications.</p><p>A two-year follow-up of the patient’s evolution was uneventful, with a great life quality.</p><p><strong>Suggested Reading</strong></p><ol><li>Borst HG, Walterbusch G, Schaps D. Extensive aortic replacement using “elephant trunk” prosthesis. <a href="https://doi.org/10.1055/s-2007-1020290"><em>Thorac Cardiovasc Surg. </em>1983;31(1):37-40</a>.</li><li>Schepens MA, Dossche KM, Morshuis WJ, van den Barselaar PJ, Heijmen RH, Vermeulen FE. The elephant trunk technique: operative results in 100 consecutive patients. <a href="https://www.ncbi.nlm.nih.gov/pubmed/11825735"><em>Eur J Cardiothorac Surg.</em> 2002;21(2):276-281</a>.</li><li>Kazui T, Washiyama N, Muhammad BA, et al. Total arch replacement using aortic arch branched grafts with the aid of antegrade selective cerebral perfusion. <a href="https://www.ncbi.nlm.nih.gov/pubmed/10921673"><em>Ann Thorac Surg.</em> 2000;70(1):3-8</a>.</li><li>Shrestha M, Martens A, Krüger H, et al. Total aortic arch replacement with the elephant trunk technique: single-centre 30-year results. <a href="https://doi.org/10.1093/ejcts/ezt359"><em>Eur J Cardiothorac Surg.</em> 2014;45(2):289-295</a>.</li><li>Zhang MH, Du X, Guo W, Liu XP, Jia X, Ge YY. Early and midterm outcomes of thoracic endovascular aortic repair (TEVAR) for acute and chronic complicated type B aortic dissection. <a href="https://doi.org/10.1097/MD.0000000000007183"><em>Medicine(Baltimore).</em> 2017;96(28):e7183</a>.</li><li>Chen Y, Zhang S, Liu L, Lu Q, Zhang T, Jing Z. Retrograde type A aortic dissection after thoracic endovascular aortic repair: a systematic review and meta-analysis. <a href="https://doi.org/10.1161/JAHA.116.004649"><em>J Am Heart Assoc.</em> 2017;6(9):e004649</a>.</li></ol>