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.