Case Presentation
A 37-year-old gentleman with a past medical history significant for
chronic obstructive pulmonary disease (COPD), Marfan syndrome, and a
previous open repair for a ruptured Crawford type I thoracoabdominal
aortic aneurysm presented to a nearby emergency department with altered
mental status and somnolence following cocaine use. He reported that for
months he had syncopal episodes and dysphagia, with chronic chest and
back pain, as well as shortness of breath. A computed tomographic
angiography (CTA) demonstrated a DeBakey type I aortic dissection, with
intact prior descending aortic replacement (Figure 1 ). On
arrival to our institution, he was in sinus rhythm and on anti-impulse
therapy. He was taken emergently for open aortic dissection repair.
Through a median sternotomy, we cannulated centrally with epiaortic
ultrasound and modified seldinger technique. Cannulae were placed and
cardiopulmonary bypass initiated with systemic cooling towards 18°C for
deep hypothermic circulatory arrest. The innominate artery was
visualized, clamped cephalad, and transected at the level of the aorta
for end-to-end anastomosis. Antegrade perfusion through the innominate
artery was maintained as we completed the left common carotid, and left
subclavian artery running anastomoses. Our distal aortic anastomosis was
completed in Zone 3 of the aortic arch with a portion of the anastomosis
to the dacron graft from the prior aortic repair.
In scenarios of normal anatomy, visualizing Zone 3 is frequently
difficult via a median sternotomy. The kyphosis and extensive COPD in
this patient made an already technically arduous situation virtually
impossible with a conventional running aortic anastomotic approach. We
placed interrupted 2-0 Ethibond plegetted valve sutures
circumferentially (Figure 2 ). Once we were satisfied with our
suture placement, we completed the anastomosis with the Cor-Knot
automated fastener (Figure 3 ) over a 22 mm Hegar dilator to
prevent aortic coarctation.
Body perfusion was resumed after 75 minutes, systemic rewarming was
started, and the ascending aorta was transected at the sinotubular
junction for proximal anastomosis as there was no root and/or valvular
pathology. We subsequently completed the debranching anastomosis to the
proximal aorta followed by atrial septal defect closure through the
right atrium. Deairing was done through the left ventricular vent, the
cross clamp was removed, rewarming was continued, the patient was
decannulated from cardiopulmonary bypass (CPB), and the chest was
closed. Cross clamp time was 197 minutes, and CPB time was 230 minutes.
Postoperatively, his course was complicated by prolonged intubation,
tracheostomy, and bacterial pneumonia. His intensive care unit and total
length of stay were 41 and 46 days, respectively. At one-month
follow-up, he was mildly hypertensive at 135/80 mmHg with a heart rate
of 99 beats per minute. Chest CTA at follow-up shows trifurcated
debranching with Cor-Knot automated fastening of the distal aortic
anastomosis (Figure 4 ). He had been decannulated from his
tracheostomy and had progressively returned to his regular activities.
He was scheduled for repeat CTA and follow-up to be done in one year.