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.