Total arch replacement through re-median sternotomy after coronary surgery

Area of Science:

• Cardiovascular Surgery
• Thoracic Aneurysm Repair
• Aortic Arch Reconstruction

Background:

• A 78-year-old male patient presented with an aortic arch aneurysm requiring surgical intervention.
• The patient had a history of off-pump coronary artery bypass grafting (OPCABG) utilizing the right internal thoracic artery (RITA) for left anterior descending (LAD) artery revascularization.
• The RITA was the sole remaining conduit supplying both the left and right coronary arteries, presenting a significant surgical challenge.

Observation:

• The patient required graft replacement of an aortic arch aneurysm.
• A previous coronary artery bypass surgery complicated the aortic repair due to the critical nature of the RITA graft.
• The surgical approach needed to avoid injury to the RITA to maintain coronary perfusion.

Findings:

• Total aortic arch replacement was successfully performed using selective antegrade cerebral perfusion.
• A re-median sternotomy approach was utilized, allowing for meticulous surgical technique.
• The right internal thoracic artery graft was preserved throughout the procedure, maintaining vital coronary blood flow.

Implications:

• This case demonstrates the feasibility of complex aortic arch reconstruction in patients with prior complex cardiac surgery.
• Selective antegrade cerebral perfusion is a valuable technique for protecting cerebral circulation during aortic arch surgery.
• Preservation of critical bypass grafts, like the RITA, is paramount in managing patients with extensive cardiovascular disease.