[Open Stent Graft Stenosis after Total Arch Replacement for Acute Aortic Dissection in a Patient with Right-sided...

We describe a patient with stenosis of an open stent graft during total arch replacement of a rightsided aortic arch. A 67-year-old man was transferred to our hospital with a diagnosis of acute type A (DeBakey type II) aortic dissection. Computed tomography( CT) imaging revealed concomitant rightsided aortic arch (RAA) and Kommerell diverticulum at the descending thoracic aorta. Total arch replacement was performed using an open stent graft over the Kommerell diverticulum. While closing the sternum, blood pressure of the femoral artery dropped to a level much lower than that of radial artery. Transesophageal echocardiography revealed an apparently new intimal flap in the descending thoracic aorta. Therefore, an axilla-femoral artery bypass and a femoro-femoral artery crossover bypass were performed to improve malperfusion of the visceral organs and lower extremities. CT imaging immediately after these procedures revealed stenosis at the non-stented portion of the open stent graft, which was located at the steep-angled site of the RAA. The pressure gradient between the upper and lower extremities was around 100 mmHg on the day of surgery, but it disappeared on postoperative day 4. Improved graft stenosis was confirmed by CT before discharge.