Operative approach
The intervention was performed in two stages. The first stage consisted
in an off-pump supra-aortic arch debranching using a trifurcated Dacron
graft. The patient was placed in supine position with his head turned
toward his right shoulder. Median sternotomy was extended into the left
jugulocarotid gutter. After exposing the ascending aorta and neck
vessels (Fig.2A), the patient received partial heparinization. He was
kept normothermic during the entire operation. A soft segment was
identified on the ascending aorta to apply a partial occluding clamp
(Fig.2B). An end-to-side anastomosis was performed on that segment with
the trifurcated graft (Fig.2C). The Dacron graft was de-aired by
removing the aortic side-biting clamp and allowing the distal limbs to
flow up from the aorta. Thereafter, each supra-aortic vessel was
detached from the aortic arch near their origin and rerouted to the
corresponding limb graft in an end-to-end manner using simple running
polypropylene sutures (Fig.2C). The debranching was performed in a
standard order, starting with the left common carotid artery and
finishing with the left subclavian artery. The three proximal arterial
stumps were ligated to prevent a type II endoleak. Small radiodense
metallic clips were circumferentially placed on the ascending aorta, 2
cm above the anastomosis with the trifurcated graft (Fig.2D). This
allowed for an accurate determination of the endoprosthesis landing
zone.
The second stage of the procedure, the TEVAR, was performed 48 hours
later under conscious sedation and regional anesthesia. Two endovascular
grafts, sized using 3D reconstruction, were successively deployedvia femoral access from zones 0 to 4, excluding the
pseudoaneursym from the aortic lumen and covering the native ostia of
the head vessels.
Postoperatively, the patient developed acute kidney injury, pneumonia
and delirium. He was discharged home after 10 days. A computed
tomography angiography done prior to hospital discharge showed excellent
results, with no endoleak (Fig.3). At one-year follow-up, he felt fully
recovered and was doing well.