Case presentation
An 83-year-old man presented with a KD and right ASA originating from
the descending aorta as the fourth supra-aortic branch passing behind
the trachea and esophagus. The KD measured 21 mm. Additionally, he had
an 83-mm thoracic saccular aneurysm on the aortic arch and a 45-mm
saccular aneurysm on the descending aorta (Figure 1).
We planned a two staged hybrid procedure using a total arch replacement
(TAR) with a frozen elephant trunk (FET) and distal extension of the
thoracic endovascular aortic repair (TEVAR).
The patient underwent a TAR using the FET technique performed through a
median full sternotomy. Initially, 9 mm tubular grafts (J Graft Japan
Lifeline Co, Ltd, Tokyo, Japan) were anastomosed to both the left and
right axillar arteries in their second portion. After systemic
heparinization, an arterial cannula was inserted from the ascending
aorta, and venous cannulas were placed through the superior and inferior
vena cavae. Subsequently, cardiopulmonary bypass (CPB) was instituted.
The right ASA was exposed just at the right side of the main bronchus
with the guidance of preoperative CT.
As the core temperature fell to 30 °C, under circulatory arrest, the
right ASA was ligated at the previous dissected part. After the left
subclavian artery was ligated at its origin, antegrade selective
cerebral perfusion (SCP) was initiated through both of the 9 mm graft
conduits anastomosed to both axillar arteries. Twelve-Fr balloon-tipped
cannulas were inserted into both common carotid arteries. The antegrade
SCP flow was maintained at 10 to 12 ml/kg/min using an independent
roller pump, and the balloon tip pressure was maintained between 30 and
40 mmHg.
The aortic arch was transected between the left common carotid and left
subclavian artery, and a 31 -120 mm FET (J graft FROZENIX Japan Lifeline
Co, Ltd, Tokyo, Japan) was inserted with direct vision without
fluoroscopy or trans-esophageal echocardiography. After deploying the
FET, a stump of the graft was anastomosed to the four-branched graft (J
Graft Japan Lifeline Co, Ltd, Tokyo, Japan) by a 3-0 polypropylene
running suture. The lower body circulation was reinstituted through a
branch graft. The proximal anastomosis with a 3-0 polypropylene running
suture was then accomplished, followed by coronary reperfusion. The
first branch was anastomosed to the right carotid artery and the second
to the left carotid artery by a 4-0 polypropylene running suture. A 9-mm
tubular graft from the right subclavian artery was anastomosed to the
first side branch using an end-to-side anastomosis. Finally, another
9-mm tubular graft from the left subclavian artery was anastomosed to
the ascending tubular graft in an end-to-side fashion. The durations of
the operation, extracorporeal circulation, aortic cross-clamping, and
circulatory arrest were 391, 185, 95, and 74 minutes, respectively.
Postoperative CT revealed good patency of the bypass graft to the
supra-aortic vessels and complete exclusion of any KD or saccular
aneurysm by the FET (Figure 2).
Three weeks after the TAR with an FET, a scheduled TEVAR was performed.
A stent graft (Gore CTAG 26 mm × 200 mm Gore & Associates, Flagstaff,
AZ, USA) was deployed in the lower descending aorta in a retrograde
fashion through a left femoral access. Subsequently, the second stent
graft (Gore CTAG 31 mm × 200 mm Gore & Associates, Flagstaff, AZ, USA)
was additionally inserted as a bridging of the previously placed FET and
first stent graft.
The patient’s recovery was uneventful. The postoperative CT showed the
complete exclusion of both aneurysms and KD by the stent graft (Figure
3). He was discharged from the hospital 10 days after the surgery
without any complications.