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Surgical Management of Acute Type a Aortic Dissection: Branch-First Arch Replacement with Total Aortic Repair

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Surgical Management of Acute Type a Aortic Dissection: Branch-First Arch Replacement with Total Aortic Repair Art of Operative Techniques Surgical management of acute type A aortic dissection: branch-first arch replacement with total aortic repair Sean D. Galvin1, Nisal K. Perera2, George Matalanis2 1Department of Cardiothoracic Surgery, Wellington Regional Hospital, Wellington, New Zealand; 2Department of Cardiac Surgery, The Austin Hospital, Heidelberg, Australia Correspondence to: A/Professor George Matalanis, Director. Department of Cardiac Suregry, PO BOX 555, Heidelberg, Victoria 3084, Australia. Email: [email protected]. Acute type A dissection (ATAAD) remains a morbid condition with reported surgical mortality as high as 25%. We describe our surgical approach to ATAAD and discuss the indications for adjunct techniques such as the frozen elephant trunk or complete aortic repair with endovascular methods. Arch replacement using the “branch-first technique” allows for complete root, ascending aorta, and arch replacement. A long landing zone is created for proximal endografting with a covered stent. Balloon-assisted intimal disruption and bare metal stenting of all residual dissected aorta to the level of the aortic bifurcation is then performed to obliterate the false lumen (FL) and achieve single true lumen (TL) flow. Additional branch vessel stenting is performed as required. Keywords: Aorta; dissection; endovascular techniques Submitted May 01, 2016. Accepted for publication May 05, 2016. doi: 10.21037/acs.2016.05.11 View this article at: http://dx.doi.org/10.21037/acs.2016.05.11 Introduction required. The following describes our technique with an emphasis on ATAAD. Acute type A aortic dissection (ATAAD) is a morbid condition with surgical mortality as high as 25% (1,2). The traditional approach of open distal anastomosis with or Interrogation of preoperative imaging without hemiarch is associated with high rates of persistent Understanding the anatomy of the dissection is of false lumen (FL) patency. This exposes the patient to paramount importance to the success of the operation the risk of ongoing end-organ malperfusion and to the (Figure 1). Ideally, a computed tomography (CT) aortogram formation of complex arch and thoracoabdominal dissection extending from the angle of the jaw to the thigh is available. aneurysms. We have described our method of “branch-first Note must be made of the position and the relationships arch replacement” previously (3,4). The technique involves of the true lumen (TL) and FL along the entire aorta. establishment of cardiopulmonary bypass (CPB) with serial Each branch vessel is interrogated for dissection and the disconnection and reconstruction of each arch branch presence of static or dynamic obstruction. Entry and re- (proceeding from innominate to left subclavian; LSCA) entry tears and fenestrations are noted. The presence of using a trifurcation arch graft with a perfusion side-arm a pericardial or pleural effusion may represent subacute port (TAPP graft, Vascutek Ltd., Renfrewshire, Scotland, rupture and the need for establishment of femoro- UK). Following completion of the innominate anastomosis, femoral bypass prior to opening the chest. Intraoperative the perfusion side-arm port is used for selective antegrade transesophageal echocardiogram (TEE) defines the cerebral perfusion (ACP). The common stem of the arch presence of aortic regurgitation, pericardial effusion, graft is proximally translocated to allow for a long landing TL and FL flows, and myocardial dysfunction that may zone, should a second stage endovascular intervention be represent coronary involvement. Epiaortic US may © Annals of Cardiothoracic Surgery. All rights reserved. www.annalscts.com Ann Cardiothorac Surg 2016;5(3):236-244 Annals of cardiothoracic surgery, Vol 5, No 3 May 2016 237 This is important both for the “branch-first arch” and also to monitor for changes in regional systemic perfusion, an early sign of malperfusion. Cerebral monitoring is carried out by a Fenestration combination of electroencephalogram bispectral index (BIS), near-infrared spectroscopy (NIRS) and transcranial doppler False lumen ultrasonography (TCD). The patient is draped widely to allow access to both groins, the neck, and the anterior chest, should True axillary cannulation or carotid intervention be required. lumen Cannulation and establishment of cardiopulmonary Aortic regurgitation bypass The choice of site for arterial cannulation is made following careful assessment of the pre-operative imaging. In the majority of cases, CPB is instituted by femoral arterial Compromised blood flow to left renal artery inflow and cavo-atrial drainage. Femoral cannulation is via a direct cutdown. Using a seldinger technique the artery is punctured using a Seldinger technique, and the guidewire is confirmed to be in the TL in the descending thoracic aorta on TEE. An elongated one-piece arterial (EOPA) cannula (Medtronic Inc., Minneapolis, MN, USA) is inserted and connected to the arterial circuit. It is important to not advance the femoral cannula too far, as this may cause the tip to be positioned high in the common iliac artery Compromised blood flow to left common with the loss of collaterals from the pelvis to lower limbs. iliac artery This is important to reduce the risk of leg ischemia or compartment syndrome. In the setting of a shocked patient, Figure 1 Stanford type A aortic dissection. Note the entry and re- it may be necessary to establish CPB peripherally (femoral entry tears in the ascending, descending thoracic and abdominal artery and femoral vein) prior to opening the chest. aorta. The left renal artery arises from the false lumen, the It is important to be alert to the risk of malperfusion dissection extend into the left common iliac artery. during establishment of CPB which may occur with any source of arterial inflow. The transition from pulsatile to non-pulsatile flow with CPB may precipitate preferential be of benefit to the surgeon in assessing TL and FL FL pressurization and TL collapse. During this time, position in the operative field. Where possible, the case careful monitoring of the arterial pressure waveforms and is performed in a hybrid operating suite with access to interrogation of TL and FL flow on TEE is paramount. on-table angiography. Detection includes noting flaccidity of the arch, high line pressures, falling NIRS, reduced TL flow on TEE, and divergence of arterial line monitoring lines which Operative techniques are recorded at multiple sites. Corrective measures can Positioning and monitoring be instituted including changing or adding extra arterial inflow sources. A simple maneuver to reduce the risk of Bilateral radial or brachial arterial lines are inserted. A malperfusion during the arch reconstruction is to leave femoral arterial pressure line is placed prior to draping, the heart partially full with continued ventilation, so that or a femoral sheath can be placed by the surgeon once the cardiac ejection contributes to TL flow. operative field is prepared. The monitoring screen is set so Alternative arterial cannulation sites include: (I) the that all pressure waveforms are visible and blood pressure can contralateral femoral artery; (II) the axillary artery; (III) the be assessed simultaneously in all major vascular territories. common carotid artery and (IV) direct TL cannulation of © Annals of Cardiothoracic Surgery. All rights reserved. www.annalscts.com Ann Cardiothorac Surg 2016;5(3):236-244 238 Galvin et al. Total aortic repair in type A dissection the ascending aorta under US guidance using a Seldinger the TAPP graft in an end-to-end fashion (Figure 2B). The technique. In extreme circumstances when CPB cannot be heart is still beating during construction of this anastomosis instituted by other methods; (V) the aorta can be transected and the patient is on full flow CPB. Cerebral perfusion is under a period of controlled exsanguination with the TL therefore maintained by contralateral flow through the directly cannulated and the aorta clamped proximally; or left common carotid artery and the associated collateral (VI) direct transapical cannulation can be performed and channels (4). The graft is de-aired and allowed to back the cannula positioned across the aortic valve with its tip in bleed to remove both air and any potential debris from the the TL of the ascending aorta. In addition, a left ventricular limbs. The side-arm of the TAPP graft is now connected to vent is placed via the right superior pulmonary vein and a a separate cerebral head circuit which is used for antegrade retrograde coronary sinus cannula is placed for the delivery flow Figure( 2B). This allows ACP to be instituted without of retrograde cardioplegia. the need for axillary cannulation. This is a major advantage in the setting of ATAAD as axillary cannulation may be time consuming and technically difficult. In the setting of Branch-first arch replacement innominate artery dissection, right axillary cannulation We use a modified trifurcation arch graft with a side-arm has the potential to create a ‘flutter valve’ effect across perfusion port (TAPP graft, Vascutek Ltd., Renfrewshire, the right common carotid artery and may precipitate Scotland, UK) for the arch reconstruction. This technique right hemispheric cerebral malperfusion. The separate allows the innominate artery to be debranched and head circuit allows us to alter cerebral flow and perfusion perfused via the TAPP graft within 10 minutes, ensuring independent of systemic flows. Cerebral flow is adjusted that antegrade TL cerebral perfusion is rapidly
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