P356. Traumatic Type A Dissection with Intimal Intussusception Managed with Total Arch Repair with Frozen Elephant Trunk

Sheraton Times Square 

Objective: A 58-year-old male presented following a motor vehicle accident with loss of consciousness. He was found to have a traumatic type A aortic dissection and underwent a hemiarch repair with bioprosthetic aortic valve replacement at an outside hospital. On postoperative day three, the patient developed absent left upper extremity pulses and severe lethargy. Imaging revealed a residual dissection extending to all three arch branches. The patient was transferred to our institution for further surgical management. On further review of imaging, an intimal intussusception causing possible dynamic flow obstruction of the arch vessels was noted. Here, we present successful management of this complication through total aortic arch repair with frozen elephant trunk.

Methods: We conducted a retrospective chart review of this patient's preoperative, operative, and postoperative course as well as relevant literature review.

Results: The patient underwent peripheral cannulation via the right axillary artery using a 10mm graft and right femoral vein, followed by repeat sternotomy. After initiation of cardiopulmonary bypass, cooling, cross-clamping, and administration of antegrade and retrograde cardioplegia, the previous ascending aorta graft was cut. The bioprosthetic valve appeared normal on inspection. After cooling to below 26C, the innominate artery was clamped and antegrade selective cerebral perfusion was initiated through the right axillary artery graft. Next, the aorta was resected. A 13Fr cerebral perfusion cannula was inserted into the ostia of the left common carotid artery for additional cerebral perfusion. A four branched hybrid prosthesis was advanced to the descending aorta through left common femoral access. The stent was deployed followed by completion of an anastomosis between the device sewing cuff and the native aorta. Systemic circulation was then restored through the graft side branch. The proximal aortic graft-to-graft anastomosis was performed followed by removal of the aortic cross-clamp and anastomosis of the 8mm graft branch to the left common carotid artery and the 10mm graft branch to the innominate. Given the fragile tissue quality secondary to injuries sustained in the MVA, as well as the deep anatomic location of the subclavian, the decision was made to ligate the subclavian artery and anastomose the left internal mammary artery to the branched graft to restore perfusion to the left upper extremity. The patient was successfully weaned from cardiopulmonary bypass. The patient recovered from surgery well and discharged to rehabilitation facility with non-disabling stroke.

Conclusions: We describe a rare case of a traumatic type A dissection, initially treated with hemiarch repair with AVR. The patient developed symptoms of a residual dissection leading to possible dynamic flow obstruction of the arch vessels due to intimal intussusception. This catastrophic complication was successfully treated with total arch replacement with a frozen elephant trunk approach and resulted in a satisfactory patient outcome.

Authors
Sarah Hoffman (1), Shaelyn Cavanaugh (2), Andrew Jones (1), Hossein Amirjamshidi (2), Kazuhiro Hisamoto (2)
Institutions
(1) University of Rochester School of Medicine and Dentistry, Rochester, NY, (2) URMC Division of Cardiac Surgery, Rochester, NY

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