Intraoperative retrograde type I aortic dissection in a patient with chronic type IIIb dissecting aneurysm

Iatrogenic acute aortic dissection of the ascending aorta during cardiac surgery is a rare but potentially fatal complication. We describe the emergency repair of iatrogenic acute aortic dissection of the ascending aorta during distal arch replacement in a patient with a chronic type IIIb dissecting aneurysm. We scheduled distal arch and descending aortic aneurysm repair through a left anterolateral thoracotomy with a femoro-femoral bypass. While trimming the proximal suture line, retrograde aortic dissection occurred from the cross-clamped site to the aortic root. Transesophageal echocardiography revealed aortic dissection at the ascending aorta. As soon as the additional median sternotomy was established, the ascending aorta was transected and antegrade selective cerebral perfusion was applied without waiting for further cooling. Total arch replacement with descending aortic and root replacements then proceeded. The patient recovered uneventfully after extensive surgical replacement of the thoracic aorta and remains asymptomatic at two years after the procedure. To prevent possible neurological complications, this patient was managed by selective antegrade cerebral perfusion at 31 degrees C because we could not afford to wait for the induction of deep hypothermia. Successful management of iatrogenic acute aortic dissection depends on immediate recognition and the appropriate choice of surgical repair.