Hybrid Arch Replacement for Retrograde Type A Dissection with High-Risk Features

P0146 

Case Video Submission 

Noah Weingarten (1), Patrick Vargo (1), Xiaoying LOU (1), Eric Roselli (1), Faisal Bakaeen (1), Edward Soltesz (1), Michael Tong (1), Shinya Unai (1), Haytham Elgharably (1), Benjamin Kramer (1), Anibal Ibanez (1), Francis Caputo (1), Jon Quatromoni (1), Ali Khalifeh (1), Lars Svensson (1), Marijan koprivanac (1)

(1) Cleveland Clinic, Cleveland, OH

Noah Weingarten    -  Contact Me
Cleveland Clinic

Patrick Vargo    -  Contact Me
Cleveland Clinic

Xiaoying LOU    -  Contact Me
Cleveland Clinic

*Eric Roselli    -  Contact Me
Cleveland Clinic

*Faisal Bakaeen    -  Contact Me
Cleveland Clinic

*Edward Soltesz    -  Contact Me
Cleveland Clinic

*Michael Tong    -  Contact Me
Cleveland Clinic

*Shinya Unai    -  Contact Me
Cleveland Clinic

♦Haytham Elgharably    -  Contact Me
Cleveland Clinic

Benjamin Kramer    -  Contact Me
Cleveland Clinic

Anibal Ibanez    -  Contact Me
Cleveland Clinic

Francis Caputo    -  Contact Me
Cleveland Clinic

Jon Quatromoni    -  Contact Me
Cleveland Clinic

Ali Khalifeh    -  Contact Me
Cleveland Clinic

*Lars Svensson    -  Contact Me
Cleveland Clinic

Marijan Koprivanac    -  Contact Me
Cleveland Clinic

Noah Weingarten    -  Contact Me
N/A

Objective: To demonstrate an efficient, single-stage approach for treating retrograde type A aortic dissections with an entry tear in the descending aorta.

Case Video Summary: A 38-year-old man presents with chest pain, hemodynamic stability, and no signs of malperfusion. CTA shows an acute retrograde type A dissection extending to the renal arteries with high-risk features: an entry tear in the descending aorta and a 360° dissection flap.

The aorta is cannulated over a guidewire. The right atrium and superior vena cava are cannulated for venous return and to enable retrograde perfusion. Retrograde cardioplegia is given. Cardiopulmonary bypass is initiated. The aorta is cross-clamped and transected.

Characteristically for a retrograde type A with an entry tear in the descending aorta, the intimal flap is filled with clot. A dissection flap extends from the ascending aorta and root into the right- and non-coronary sinuses with detachment of the non-coronary commissure. The aortic valve is trileaflet with no major defects.

The media of the right- and non-coronary sinuses is reconstructed with a felt insert and 5-0 prolene. Additional pledgeted suture is placed in the middle of the noncoronary sinus due to redundancy and to improve remodeling. All aortic valve commissures are re-suspended with pledgeted 4-0 prolene.

After deep cooling, circulation is arrested and retrograde perfusion is given. The arch is inspected revealing no unexpected tears.

Given the location of a primary intimal tear in the descending aorta, the absence of tears in the arch, and lack of dissection in the head vessels, the decision is made to perform a hybrid arch replacement with subclavian artery stenting.

A 15 cm frozen elephant trunk is deployed in the true lumen with a proximal landing zone in zone 2. A subclavian artery stent graft is advanced. A suture is placed on the lesser curvature to prevent stent dislodgment. A hole is made in the stent graft. A 13.5 mm stent is advanced over a guidewire into the left subclavian artery. The frozen elephant trunk is fixed in zone 2 with 4-0 prolene. The distal anastomosis is created with a 30 mm single-branched tubular graft using 4-0 prolene. De-airing is performed, circulation resumed, and rewarming is initiated. True lumen stent positioning is confirmed on echocardiogram.

The supracoronary proximal anastomosis is created, bypass is weaned, and the patient is decannulated. True lumen flow is again confirmed on echocardiogram.

Circulatory arrest time is 36 minutes. The patient is extubated on postoperative day 2 and discharged on day 8. CTA four months postoperatively reveals stable aortic dimensions, no endoleak, and a patent left subclavian artery stent.

Conclusions: Hybrid arch replacement with subclavian artery stenting for retrograde acute type A dissections is a simple, efficient way to treat the primary tear – a goal of every acute dissection surgery. This technique allows for single-stage, multi-segment aortic repairs in patients with risk factors for fast dissection propagation and growth. Fixating the frozen elephant trunk in zone 2 rather than zone 3 may reduce circulatory arrest time, bleeding complications, and left recurrent laryngeal nerve injury risk. Stenting the left subclavian artery is simpler then debranching, promotes remodeling, and reduces the risk of retrograde perfusion from the subclavian into an aortic false lumen if only covered by the main stent.

Dissection