Innovative hybrid procedure for dissection thoracic aorta in a patient with a previous bentall operation

In dissection aorta involving the whole aorta from the left subclavian artery surgical repair may be a high risk procedure while an endovascular procedure would not be feasible by itself in view of the absence of a safe landing zone and the risk of blocking the brain and arm circulation. A hybrid procedure is presented to tackle such a problem.

A 42-year-old Marfan, with a previous history of a Bentall procedure 10 years back, presented with acute thoracic aortic dissection. Investigations revealed a large dissection starting from the left subclavian to the right renal artery. Since a safe landing zone was required which would block off the arch vessels, first a redo sternotomy was performed and under femoro-femoral cardio-pulmonary bypass (CPB), a short segment of Dacron graft was interposed between the previous Bentall graft and the arch of aorta. On to this graft, 2 additional grafts were anastomosed. A 14 X 9 bifurcated graft to go to the right brachiocephalic and the left common carotid, and a 9 mm side arm to facilitate the positioning of the endograft. After coming off CPB, a guide wire was manipulated from the femoral artery into the side graft with a snare and the endograft was inserted.

The false lumen was successfully obliterated. The patient made a complete recovery with no neurological deficit.

A hybrid procedure with an innovative technique of preserving the brain and arm circulation and a new technique of facilitating proper positioning of the endostent with a side arm conduit is presented.