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A 55 year old gentleman who had previously suffered from a type A aortic dissection 3 years
previously, which had been treated with an aortic root replacement and arch replacement,
has been followed up by the cardiologists, and referred when his descending aorta had
enlarged to 6.5cm. The false lumen had always remained patent post surgery which is a
known risk factor for subsequent aneurysm formation. From the scans below the previous aortic valve can be seen and the
anastomosis of the Dacron tube to the distal arch can also be clearly seen. Whether
each kidney originates from a different lumen, as the dissection extends down into the abdominal aorta is difficult to seen in the images shown.
This gentleman needs his thoracic aorta replaced, due to it enlarging and being over 6cm. The
descending aorta is relatively normal sized at the diaphragm, so replacing the aorta
from the previous Dacron anastomosis in the distal arch to the diaphragm via a left
thoracotomy with a distal fenestration would be a fair plan. If the abdominal aorta subsequently became
aneurysmal then this could be replaced as a separate procedure.
The top end of your replacement is distal to the left subclavian so in theory left heart bypass could be used, however in the
setting of a redo situation a circulatory arrest would probably be the option to take.
With regard to the bypass setup traditionally femoral femoral bypass with venting the heart via the superior or inferior pulmonary vein
could be an option. An alternative more recently would be to also cannulate the right axillary
artery, so that the circulatory arrest time could be kept short if a clamp could be placed
on the arch of the aorta or the graft while the anastomosis both top and bottom are being performed.
If it is possible to clamp the thoracic aorta just above the diaphragm then femoral perfusion could be
continued during the anastomosis. With single femoral perfusion unless a fenestration is preformed distal to your clamp there will be some lower body
malperfusion if the left and right iliac arteries originate from different dissection lumen.
The difficulty with this option is that the aorta at the crux of the diaphragm is
difficult to access, especially in an obese patient like this one, and also it is
calcified in its wall making stitching difficult.
An alternative surgical option would be to replace the whole thoracic and abdominal aorta
in one sitting and use the Cosselli graft for visceral artery reimplantation
With either option spinal artery reimplantation probably via patch reimplantation should be used.
Apart from bleeding the major risk for this procedure is paraplegia.
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