Surgical management
A median sternotomy was performed. Cardiopulmonary bypass was established by arterial cannulation of the right axillary artery through an 8mm interposition Dacron graft and venous cannulation with a standard two-stage venous cannula. The innominate and left common carotid arteries were freed up with soft tissue dissection and snared (Figure 4A). After cross clamping the ascending aorta, cold crystalloid (Custodiol) cardioplegia was administered retrogradely through the coronary sinus as well as antegradely though the right coronary artery ostium. The dissected ascending aorta was transected and inspected, to find an entry tear superiorly and laterally of the left main coronary ostium in close proximity. The LM stent was also visible, protruding into the aortic lumen (Figure 4B). The crucial decision was made to preserve the aortic root and seal the entry tear using a single pledged 5-0 polypropylene suture. After reaching 25oC, CPB was arrested and the aortic cross clamp removed for inspection of the aortic arch. The origin of the epiaortic vessels as well as the aortic arch were intact. Unilateral selective antegrade cerebral perfusion was achieved through right axillary artery cannulation by snaring the innominate, left common carotid arteries and clamping the origin of left subclavian artery. A straight tube 28mm Dacron graft was used for ascending aortic reconstruction with hemiarch replacement. During the procedure, continuous cerebral oximetry monitoring with a pre-installed INVOS (Medtronic) was used.
The patient’s postoperative course was uncomplicated, and TTE showed no evidence of left ventricular systolic dysfunction. At 8-month follow-up, CTA demonstrates no residual aortic dissection and patent coronary stents (Figure 5).