Overview: To describe a new endovascular procedure for acute type A aortic dissection (TAAD) repair. Methods: Between 2013 and 2016, 12 patients (average age 54±9.6 years; 10 men) with acute TAAD (mean EURO score 11.4%±3.2%, range 5-17) and unfit for surgery underwent thoracic endovascular aortic repair (TEVAR) with 2 periscope grafts to preserve blood supply to supra-aortic branches plus bypass grafting as needed. If the ascending aorta was dilated to >40 mm, sternotomy was performed to wrap the ascending aorta and reduce its diameter to accommodate the aortic stentgrafts. Results: All patients were successfully treated. Seven patients required bypass grafting, and most of the patients had periscope grafts to the innominate/right common carotid artery and left common carotid artery; only 3 patients had the left subclavian artery preserved. All patients exhibited good hemodynamics and normal pressures after the procedure. The mean procedure time and blood loss were 4.5±1.0 hours and 217±111.5 mL, respectively. Two patients treated emergently died shortly after surgery from multiorgan failure. The average follow-up duration was 17±14.5 months (range 2-42) in the 10 survivors. The remaining patients recovered and none experienced stent-graft thrombosis, stroke, or peripheral artery embolism during follow-up. Conclusion: A procedure that combines sandwich/periscope grafting with TEVAR, wrapping of the aorta, and supra-arch bypass grafting can be used to treat patients with acute TAAD.

Despite its invasive nature, open surgical repair is still the first choice to treat aortic arch aneurysms. With the advancement of endovascular technology, thoracic endovascular aortic repair (TEVAR) has gained popularity in treating aortic aneurysms; however, blood flow preservation of the supra-arch branches remains a complicated challenge. This case report describes a hybrid procedure that successfully treated a patient with aortic arch aneurysm by combining the parallel grafts perfused by retrograde flow in the TEVAR procedure and a carotid-subclavian artery bypass.

Circulation arrest is widely used during total aortic arch replacement. However, the conventional procedures have high morbidity and mortality. We modified the hybrid procedure by optimizing the sequence of anastomosis between the graft and aorta. As a result, the time of extracorporeal circulation was obviously shortened, and cardiac arrest was needed only during the two anastomoses of the aorta with aorta graft main body. In addition, both circulation arrest and deep hypothermia were avoided. Leakage was also prevented by creating a lengthened sealing zone for stent graft deployment.

Rationale:Levator resection has become a routine procedure for patients with severe Marcus Gunn jaw-winking synkinesis (MGJWS). To optimize the surgical outcome, adult patients need to be kept awake, or easily aroused and responsive to verbal commands during the operation. However, levator resection is commonly performed under general anesthesia in pediatric patients. In the present case, we described a successful anesthetic protocol of conscious sedation with local anesthesia for levator resection in a child.Patient concerns:A 10-year-old boy with MGJWS was admitted to our hospital and scheduled for levator resection. The patient was born through a normal delivery and had no previous history of allergy, no comorbidity, and no history of receiving anesthesia or operation. The laboratory tests of the patient were unremarkable.Diagnoses:The diagnosis of MGJWS was made by two experienced ophthalmologists.Interventions:A 10-year-old boy with MGJWS was admitted to our hospital and scheduled for levator resection. The levator resection was performed under monitored conscious sedation with dexmedetomidine and local anesthesia.Outcomes:Patient with spontaneous breathing responded normally to verbal commands throughout the operation, and no adverse events occurred. The patient and ophthalmologist reported high satisfaction with anesthesia management.Lessons:Dexmedetomidine-based monitored conscious sedation with local anesthesia is a feasible alternative to general anesthesia for levator resection in collaborative patients.