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.