Comment
Rupture at the site of KD has been previously reported in the literature. Austin et al., reported 19% incidence of rupture at the site of KD with 100% mortality.2
Surgical approach in a patient with aortic tear/rupture or acute dissection is centered on excluding the site of tear/rupture from the circulation to prevent exsanguination.
Open repair for type A IMH and proximal DTA rupture requires median sternotomy and AAo, total arch and proximal DTA replacement. Other option would be to do a two-stage procedure with total arch replacement and placement of an elephant trunk. However, two stage elephant trunk carries a significant interval mortality due to aortic cause, and also significant number of patients do not undergo second stage thoracotomy for completion.3 Conventional elephant trunk also does not address the DTA rupture immediately.
The various options for hybrid repair in this setting include total arch replacement and elephant trunk placement followed by endovascular completion,4 total arch replacement and placement of a frozen elephant trunk (FET),4 subclavian artery bypass followed by zone 2 TEVAR and coil embolization of SCA,4 or a single stage total aortic arch debranching and TEVAR with zone 0 landing.5 Totally endovascular exclusion of ruptured KD with SCA stenting has also been demonstrated.6
Pathology of the AAo and AoA in our patient mandated AAo and arch replacement. Lack of landing zone between carotid and subclavian ostium and large size of the aortic arch precluded the option of retrograde TEVAR with zone 2 placement. We chose the option of FET as it can be safely deployed in this narrow area. Stent graft in DTA also provides a more stable landing zone for retrograde TEVAR compared to the standard elephant trunk.7
We ligated the origin of both the subclavian arteries as it has been shown to be the source of type II endoleak.(4,8)However, we had type Ia endoleak after completion of FET and this was remedied with more extensive zone 0 landing in the ascending aortic graft. Initial performance of subclavian-carotid bypass and carotid debranching gave us flexibility to better exclude the site of tear and fix type Ia endoleak with retrograde TEVAR.