Staged Hybrid Repair of Chronic DeBakey Type I Aortic Dissection after Previous Lemole Sutureless Ring Graft Replacement

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Cardiothoracic Resident Case Report Competition 

William Frankel (1), Patrick Vargo (2), Eric Roselli (3)

(1) Cleveland Clinic Foundation, Cleveland, OH, (2) Cleveland Clinic, Cleveland, Ohio, (3) Cleveland Clinic, Cleveland, OH

William Frankel    -  Contact Me
Cleveland Clinic Foundation

Patrick Vargo    -  Contact Me
Cleveland Clinic

*Eric Roselli    -  Contact Me
Cleveland Clinic

William Frankel    -  Contact Me
Cleveland Clinic Foundation

Background: In the past, some surgeons advocated for the use of sutureless ring grafts for repair of acute aortic dissection to mitigate anastomotic complications when suturing to friable tissue and prolonged ischemic times when performing multiple anastomoses. Over the years, there has been limited uptake of this procedure, and there remains a paucity of data regarding its long-term durability.
Case Summary: We present the case of a 54 year old male patient with an ACTA2 pathogenic variant and strong family history of aortic aneurysmal disease who presented to our center for evaluation and management of a chronic DeBakey type I aortic dissection. A decade prior, he presented to an outside hospital with chest pain and syncope, was found to have an acute DeBakey type I aortic dissection involving the bilateral common carotid arteries and extending distally to the left common iliac artery, and promptly underwent emergency repair with aortic valve resuspension and a limited supracoronary ascending aortic replacement. Intraoperative course was complicated by right hemispheric stroke with minimal residual left-sided sensorimotor deficits. After, he remained active and asymptomatic from a cardiovascular standpoint, however, surveillance CTA scans revealed a mildly dilated aortic root at 4.5 cm along with aneurysmal degeneration of the chronic dissection with a maximal diameter of 5.4 cm in the aortic arch/proximal descending thoracic aorta. After initial consultation, he elected to pursue surgical treatment, and underwent redo sternotomy with cardiopulmonary bypass established via a side graft to the right axillary artery and dual stage venous cannulation through the right atrium. Under deep hypothermic circulatory arrest with selective antegrade cerebral perfusion, the aorta was incised above and below the previous repair. On inspection, we observed extensive BioGlue and felt around the previous anastomoses along with two rigid plastic rings consistent with a previous Lemole sutureless ring graft. After careful dissection and excision of the prostheses, we performed a zone 1 branched stented anastomosis frozen elephant trunk repair (B-SAFER) with a stent graft deployed under direct vision in the descending thoracic aorta, another stent graft deployed in the left subclavian artery, and a multi-branch graft to reconstruct the aortic arch with reimplantation of the left common carotid and innominate arteries. Last, a valve sparring aortic root reimplantation was performed using a Valsalva graft sewn over a Hegar dilator. Surveillance CTA scans revealed a durable repair and demonstrated a stable maximal aortic diameter of 5.3 cm in the mid descending thoracic aorta distal to the previous repair. After 4 years, he underwent completion endovascular repair of the thoracoabdominal aorta with covered stent grafts in zones 3–5 and bare metal stents in zones 6–9 (PETTICOAT). At last clinical follow-up 18 months after repair, CTA scan revealed a durable repair with stable aortic dimensions and no evidence of aortic insufficiency or left ventricular dysfunction on echocardiogram.
Conclusions: Innovative procedures beget new complications which in turn require innovative solutions. In patients with aortopathy and previous limited repair of acute DeBakey type I aortic dissection with a Lemole sutureless ring graft, total aortic reconstruction with a staged hybrid approach can be performed with acceptable outcomes.

Adult Cardiac