Approaching a Brachiocephalic Artery Aneurysm with Porcelain Aorta: How I do it

P0057 

Case Video Submission 

German Chaud (1), JOAQUIN GUNDELACH (2), Pablo Filippa (3), Jaime Horta (4), gustavo Meriño (4), Marcos Durand (4), carolina gonzalez (4)

(1) Hospital las higueras, Tacahuano, Concepcion, (2) LAS HIGUERAS, CONCEPCION, Chile, (3) CHU Sainte Justine, Montréal, QC, (4) Hospital las Higueras, Talcahuano, concepcion, BI

German Chaud    -  Contact Me
Hospital las higueras

JOAQUIN GUNDELACH    -  Contact Me
LAS HIGUERAS

Pablo Filippa    -  Contact Me
CHU Sainte Justine

Jaime Horta    -  Contact Me
Hospital las Higueras, Talcahuano

gustavo Meriño    -  Contact Me
Hospital las Higueras, Talcahuano

Marcos Durand    -  Contact Me
Hospital las Higueras, Talcahuano

carolina gonzalez    -  Contact Me
Hospital las Higueras, Talcahuano

German Chaud    -  Contact Me
Institute de Cardiologie et Pneumonologie de Quebec

Approaching a Brachiocephalic Artery Aneurysm with Porcelain Aorta: How I do it
German J. Chaud; Joaquín Gundelach; Marcos Durand; Pablo Filippa; Jaime Horta; Carolina González; Gustavo Merino
Hospital Las Higueras, Talcahuano, Concepcion, Chile.
Objective: To show our institutional approach for patients with brachiocephalic aneurysm and porcelain aorta.
Case Video Summary: A 51-year-old male patient was transferred to our clinic from a rural area because of a pulsatile mass in the neck. Personal background includes a severe smoking habit and a STEMI event a few months before treated with a drug eluting stent in the main trunk. CT angiogram revealed a 48 mm aneurysm of the brachiocephalic arterial trunk partially thrombosed and a porcelain aorta including ascending and aortic arch portions. Aortic root was measured at 44 mm. TTE demonstrated good LVEF and severe aortic insufficiency with central jet due to annular dilatation. Coronary angiogram revealed severe main trunk stenosis because of calcium progression.
How I Do It:
●Cannulation strategy: A right supraclavicular incision with exposure of the right subclavian and the common right carotid artery was performed, and the latter was cannulated with a 12 Fr arterial cannula (Quebec method). After full sternotomy, central arterial cannulation was performed in zones 1.
●CPB and cerebral perfusion strategy: After CPB was initiated, patient was cooled at 26°C. Meanwhile, left carotid artery was ligated and an end-to-end anastomosis was carried out with a trifurcated Dacron graft. ●Aortic replacement: At 26°C, antegrade Del Nido cardioplegia was infused by retroplegia and completed in the right coronary ostia. Once in circulatory arrest, the brain was perfused by both carotids, the braquicephalic trunk was resected leaving a common trunk for a later anastomosis. The aorta was also resected from zone 1 in the arch until de sinotubular junction proximally. After aortic resection, significant amount of calcium protrudes like cauliflower from the intima. The aorta was then replaced distally with a 30 mm straight dacron graft, with 4-0 pledgeted suture and "U" reinforcements in the back wall. Subsequently, an aortic cannula was placed in the graft, systemic CPB and rewarming was started.
●Root treatment: Because of moderate dilatation mainly in the non-coronary sinus and severe calcification of both coronary ostiums, aortic root was preserved and a standard AVR with a 25 mm Magna Ease was executed.
●Completion of Aortic replacement: Proximal aortic graft anastomosis was accomplished with a 4-0 running prolene and was reinforced with teflon felt. Once the Aortic cross clamp was released we performed an end-to-end anastomosis of our now bifurcated graft with the remaining brachiocephalic arterial trunk. Finally, by partially clamping the straight aortic tube, proximal anastomosis of the bifurcated graft was constructed, concluding the procedure once the cerebral circulation was unclamped through the carotid artery.
●Coronary artery stenosis: while rewarming, severe anterolateral ventricular hypokinesia was found in TEE. An internal saphenous vein was harvested and a coronary bypass was performed to the left anterior descending artery, showing resolution of wall abnormality. Conclusion: This case represents several challenges in decision making, cannulation strategy, cerebral as well as myocardial protection, and root treatment in a in a patient with porcelain aorta.

Aortic Arch