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).