A punch-assisted unroofing technique for anomalous aortic origin of coronary arteries

We describe a punch-assisted unroofing technique for anomalous aortic origin of coronary arteries (AAOCA) with an intramural course. Conventional unroofing can be technically demanding because the extent of resection must balance adequate relief of stenosis against the risk of aortic wall or valvular injury. A 4-mm aortic punch, selected based on the long-axis diameter of the slit-like coronary orifice, was used to create stepwise, controlled resection of the common wall between the aorta and the intramural coronary artery. The punch provided a predefined resection width and facilitated enlargement of the neo-ostium. Four overlapping punch applications achieved approximately 4-5 mm of unroofing, and the resection margin was reinforced with continuous 7-0 monofilament sutures. Postoperative computed tomography confirmed enlargement of the coronary orifice and resolution of stenosis. This technique provides a simple and reproducible method for unroofing that may reduce operator-dependent variability and facilitate standardized surgical management in selected patients with AAOCA.