Case Report
A 72-year-old male with adenocarcinoma but no other known major comorbidities was scheduled for right nephrectomy; a routine echocardiography showed an undiagnosed dilated ascending aorta with aortic insufficiency. Subsequent computed tomographic angiography (CTA) showed a dilated ascending aorta (58 mm) and arch (particularly in zone 1, 49 mm), as well as proximal thoracic aorta (36 mm). The aortic root was normal but a dilated sinotubular junction resulted in a moderate-to-severe aortic insufficiency. Biventricular contractility was preserved and there was no coronary artery pathology. The patient underwent uncomplicated nephrectomy and came back for aortic surgery 6 months later.
A 28/30 mm diameter Thoraflex Hybrid with a stented length of 100 mm was modified to have only two branches: one main (16 mm) for SAT reimplantation, and one lateral (10 mm) for systemic perfusion. A separate trifurcated Gelweave surgical graft (10/8/8—16 mm) (Terumo Aortic) with a 10-mm side perfusion branch was used to connect the SAT vessels (Figure 1).
Median sternotomy was performed and the usual incision was extended in a small bilateral supra-clavicular cervicotomy to improve SAT access and harvesting. Central cannulation using a 10-mm side graft was via the right intrathoracic subclavian artery (RSA). The right atrium and right superior pulmonary vein were cannulated for venous return and venting. A homemade 4-branched perfusion circuit was used for extracorporeal circulation (ECC) and cerebral antegrade perfusion (Figure 2). Four branches of equal diameter allow systemic perfusion by a single pump head while connected to RSA, LSA, LCA and prosthesis branch. Perfusion is kept at full flow for ECC and redistributed depending on physiological systemic resistence; then lowered to 10—12 mL/kg/min when the innominate is clamped for isolated cerebral perfusion.
The patient was cooled to 26°C for hypothermic circulatory arrest (HCA). On beating heart during the initial cooling phase, LCA and LSA were isolated, resected and anastomosed to the two lateral branches of the Gelweave prosthesis; cannulation and perfusion via the graft’s side branch allowed complete antegrade cerebral perfusion.
After debranching and at 30°C core temperature, the aorta was cross-clamped and opened and Custodiol cardioplegia administered into the coronary ostia. The aortic valve, unsuitable for repair, was replaced with a Inspiris Resilia 25-mm prosthesis (Carpentier Edwards). At 26°C, the innominate artery was clamped, systemic circulation stopped, and selective antegrade perfusion began at 12 mL/kg/min. The arch was then opened and the landing zone (zone 2) was reinforced with a teflon strip. The distal stent-graft portion was deployed in the descending aorta and its reinforced collar was sutured to the aortic isthmus; after cannulation of the lateral branch systemic perfusion was resumed and rewarming started. The proximal anastomosis was then completed and cross-clamp released. The innominate was detached and anastomosed to the last branch of the second prosthesis. Finally, the main bodies of the FET and surgical grafts were anastomosed together.
At the end of the procedure, we found an extensive RSA wall lesion which we resected and anastomosed to the innominate with a 8-mm interposed graft: ECC, aortic clamping, and HCA times were 230, 118, and 27 minutes, respectively (Figure 3). The patient was extubated after 12 hours without any neurological damage. On postoperative day (POD) 4, he developed temporary respiratory insufficiency requiring tracheostomy. A moderate renal insufficiency developed and reverted after three days of continuous veno-venous hemofiltration. He was discharged from intensive care on POD 14 and transferred to rehabilitation without any other major problem.