Simultaneous total arch and descending aorta replacement via the left thoracotomy for extensive mega aorta.

P0308 

Case Video Submission 

Shinichiro Ikeda (1), Tomomi Nakajima (1), Takayuki Gyoten (1), Osamu Kinoshita (1), Toshihisa Asakura (1), Akihiro Yoshitake (1)

(1) Saitama Medical University International Medical Center, Hidaka, Japan

Shinichiro Ikeda    -  Contact Me
Saitama Medical University International Medical Center

Tomomi Nakajima    -  Contact Me
Saitama Medical University International Medical Center

Takayuki Gyoten    -  Contact Me
Saitama Medical University International Medical Center

Osamu Kinoshita    -  Contact Me
Saitama Medical University International Medical Center

Toshihisa Asakura    -  Contact Me
Saitama Medical University International Medical Center

Akihiro Yoshitake    -  Contact Me
Saitama Medical University International Medical Center

Shinichiro Ikeda    -  Contact Me
N/A

Objective: Clamshell or antero-lateral partial sternotomy is used for replacing extensive thoracic mega aorta. Here, we present our approach, left thoracotomy/posterolateral thoracotomy for this pathology.

Case Video Summary:
This is a 46-year-old male with a history of chronic kidney disease. The patient was incidentally diagnosed with chronic Stanford A aortic dissection aneurysm during an inguinal hernia work-up.

A CT scan showed type A aortic dissection starting from the distal ascending aorta to the iliac artery with 66 mm aortic arch and 63 mm descending aorta. The size of the distal descending aorta decreased to 35mm and the abdominal aorta was dilated to 50mm. The Adamkiewicz artery was identified at the level of Th8. We decided to perform total arch and descending aorta replacement simultaneously via left thoracotomy.

In the beginning, in supine position, the left femoral artery and vein were exposed for arterial and venous cannulation. The patient was positioned in right decubitus potion. The skin incision was made from the level of anterior axillary line to the tip of the scapula. The 4th intercostal space was opened, and posterior 4th rib and anterior 5th rib was divided for the further exposure. After systemic heparinization, venous and arterial cannulas were inserted via the left femoral vein and artery and cardiopulmonary bypass was initiated. The pericardium was opened to expose the heart and the ascending aorta. The left upper pulmonary vein was exposed outside of the pericardium. Left ventricular vent was inserted and advanced into the left ventricle while passing it along the left atrium wall. A transesophageal echocardiogram was used to confirm the position of the cannula in the left ventricle. A root cannula was placed in the ascending aorta. The ascending aorta was cross clamped to give antegrade cardioplegia. Then, mid descending aorta (Th7 level) was clamped, and upper body circulatory arrest was started at bladder temperature 25 ℃. The lower body was perfused from the femoral artery cannula. 15Fr, 12 Fr, 12Fr cannula were placed into the arch vessels for selective antegrade cerebral perfusion. First, the proximal anastomosis was performed at the distal ascending aorta where there was no dissection with a four-branched graft (J graft 26mm 4 branched, Japan lifeline, Tokyo). The graft was deaired via a perfusion from one of the branches. Rewarming was started. The head vessels were individually anastomosed to the branches of the graft from the innominate artery. The Adamkiewicz artery was reconstructed with a 10mm graft. The graft for the Adamkiewicz artery was attached the main graft. Finally, the distal anastomosis to the distal descending aorta was performed at the level of Th9. The heart was deaired from the root vent and left ventricular vent and weaned from the cardiopulmonary bypass. The distal anastomosis site was wrapped with a Gore-Tex sheet to prevent the adhesion for the future surgery of abdominal aortic aneurysm. Postoperatively, the patient recovered without any complications and was discharged home on the postoperative day 18. A post operative CT scan demonstrated the almost whole thoracic aorta was replaced with a graft without any anastomosis issues.

Conclusions: The left thoracotomy provides an excellent view of the whole thoracic aorta for simultaneous total arch and descending aorta replacement. A left ventricular vent can be inserted through the left upper pulmonary vein.

Descending/Thoracoabdominal Aorta