Concomitant Reconstruction of Arch Vessels during Repair of Aortic Dissection

Abstract

I n the presence of neurologic symptoms, surgical treatment of acute aortic dissection requires special attention. Whether repair of the ascending aorta needs to be supplemented by reconstruction of the arch vessels is still uncertain. There are few published papers 1,2 concerning the successful concomitant repair of arch vessels. Here we report the successful repair of a brachiocephalic artery, followed by reconstruction of the ascending aorta with the patient in profound hypothermia. Case ReportIn November 2012, a 40-year-old man was admitted to a regional hospital after the sudden onset of severe chest pain. An emergency-unit physician established a preliminary diagnosis of type A acute aortic dissection. Soon thereafter, the patient was transferred to our institution. At the time of admission, he was drowsy and reported right-hand numbness. No pulses were present in the right upper extremity, and the right carotid pulse was diminished. A bedside transthoracic echocardiogram confirmed the presence of an intimal flap in the ascending aorta. There were no signs of cardiac tamponade, and the patient was hemodynamically stable. We proceeded with an emergent 64-slice multidetector computed tomographic (MDCT) scan (Fig. 1), which showed type A acute aortic dissection with 3 intimal tears. One tear was at the left main coronary ostium, and the 2 others were at the level of the aortic arch-the second between the brachiocephalic and left carotid arteries, and the third below the left subclavian artery. The right subclavian artery was proximally occluded, and the flow in the right common carotid artery was diminished by false-lumen compression. The coronary arteries were free of disease.Our surgical plan was to reconstruct the brachiocephalic artery while the patient was cooling down in preparation for deep hypothermic circulatory arrest (DHCA). We established extracorporeal circulation via transventricular (apical) arterial and standard venous cannulation. We exposed the brachiocephalic artery in a usual manner (by means of a separate incision on the right side of the neck), and, as the patient's core temperature decreased to 22 °C, we constructed end-to-end anastomoses between branches of a bifurcated Y graft (12 × 6 mm) and the carotid and subclavian arteries. We then conducted the remnant of the Y graft into the anterior mediastinum, separately cannulated the arterial branches with intraluminal cannulas, and began antegrade cerebral perfusion (ACP) at a flow rate of 350 mL/min.During DHCA (54 min at 18 °C), a separate 30-mm Dacron graft was used for hemiarch reconstruction (the distal anastomosis having been secured by suturing the Case Reports

Urgent carotid stenting before cardiac surgery in a young male patient with acute ischemic stroke caused by aortic and carotid dissection

“…Regarding stenting of the brachiocephalic and carotid artery combined with aortic dissection surgery, there are no clear guidelines 5 . Sporadic case reports are published, with stenting after, or during the surgery of aortic arch (hybrid procedures) [6][7][8] , by performing temporary femoral-carotid artery bypass 9 , or by successful repair of the brachiocephalic artery followed by reconstruction of the ascending aorta with the patient in profound hypothermia 10 . To the best of our knowledge, there has been no published report on carotid stenting in acute ischemic stroke prior cardiosurgery.…”