Deep Dive Into Aortic Surgery: Acute Type A Dissection—Aortic Rupture

This video demonstrates how the surgical team managed to save an elderly woman who presented initially with tamponade and contained aortic rupture, but subsequently developed frank aortic rupture. The patient underwent aortic root and hemi-arch replacement under this critical circumstance. The patient had a full recovery without any neurological complications.

First, a sternotomy was performed using an electrical saw. Systemic heparinization was initiated. The aortic dissection was initially contained. After hemopericardium was released through a small pericardial window, the patient’s blood pressure went up and her ascending aorta ruptured.

Cardiopulmonary bypass was quickly initiated with femoral arterial and femoral venous cannulations. All exsanguinated blood was salvaged from the pericardium. A 16 Fr LV vent was inserted via the right superior pulmonary vein and cooling toward 20 degrees Centigrade was initiated. Under a low-flow condition, an atraumatic aortic cross-clamp was applied across the distal ascending aorta to stop further exsanguination from the ascending aorta. The mid ascending aorta was then transected. Diastolic arrest was achieved with direct ostial antegrade cardioplegia delivery. A large amount of clot was removed from the dissected layers of the aorta. Care was taken not to dislodge the clot into the aorta.

Bio-Bentall Procedure—French Cuff Technique

The aortic valve was assessed, both coronary arteries were visualized, and the aortic root was carefully mobilized circumferentially. The aortic root was dissected completely. The left and right coronary buttons were fashioned. Traction sutures were also placed above the commissures and hitched up to provide an excellent exposure of the aortic valve. The aortic leaflets were resected using 2-0 Ethibond Excel annular sutures with pledgets. The pledgets were placed neatly below the aortic annulus, especially at the nadir of the annulus to even the tensions created by the sutures. The annulus was sized and a 23 mm Inspiris valve and 28 mm Gelweave Valsalva graft were selected. 

The “French Cuff” technique was used (1). The annular sutures were passed through the prosthesis and the folded edge of the Valsalva graft. The sutures were clipped and cut. The valve conduit was parachuted down, and the sutures were tied one by one around the annulus. A second “hemostatic” layer was achieved by using three 4-0 running Prolene sutures that incorporated the remnant of the aortic wall, the everted edge of the “French Cuff.” The suture was tightened circumferentially and tied.

Coronary Button Reimplantation

Bovie electrocautery was used to create a hole for the left coronary button, which was reimplanted using a 5-0 running Prolene suture. The aortic root was pressurized and tested by delivering a full dose of antegrade cardioplegia. The hemostasis was satisfactory. Similarly, the right coronary button was prepared and reimplanted using a continuous 5-0 running Prolene suture, using a left-hand technique to perform this anastomosis to ensure that a full thickness bite with each stitch was achieved along the interior border of the coronary button.

Ascending Aortic and Hemiarch Replacement

Once the nasopharyngeal and rectal temperatures reached 20 degrees Celsius, the patient was positioned head down, CPB was terminated, and the patient’s blood volume was emptied out into a reservoir. Deep hypothermia circulatory arrest was timed from this point onward. At this point, the aortic cross clamp was removed, and the ascending aorta was completely resected. The under surface of the aortic arch was beveled from 1 cm below the innominate artery to 1 cm medial to the ligamentum arteriosum. The ostia of the head and neck vessels were inspected carefully from the inside of the arch. 

Selective Antegrade Cerebral Perfusion

Antegrade cerebral perfusion was initiated with direct innominate artery cannulation (10ml/kg/min). Retrograde flow was observed from both the left common carotid artery and the left subclavian artery. Cerebral saturation was carefully monitored throughout the deep hypothermic circulatory arrest period via INVOS. 

Hemiarch Anastomosis

The distal aorta was measured and reconstructed using a Teflon sandwich technique. A 26 mm Vascutek Anteflo graft with a single 8 mm side arm was used. The anastomosis was performed using a 3-0 running Prolene suture. A cannula was then inserted to the side-branch of the Anteflo graft for reperfusion. The graft was then deaired and the distal aortic reconstruction was inspected for hemostasis. A full body antegrade perfusion was now initiated. This marked the end of deep hypothermia circulatory arrest and selective antegrade cerebral perfusion. The aortic root graft to Anteflo graft anastomosis was performed using a 3-0 running Prolene suture. The suture was tied, the heart was deaired, and the patient was weaned from CPB uneventfully. 

A bipolar temporary pacing wire was inserted superficially in the right ventricular myocardium. Hemostasis was carefully checked, and Protamine was given to reverse the heparin effect. Three 32 Fr soft drains were inserted. Postprocedural transesophageal echocardiography showed adequate regional wall motion, and no valvular dysfunction. The patient had a complete postoperative recovery without any neurological deficits.

References

1. Yan TD. Mini-Bentall Procedure: The "French Cuff" Technique. Ann Thorac Surg. 2016 Feb;101(2):780-2. doi: 10.1016/j.athoracsur.2015.06.092. PMID: 26777944.

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