An Indigenous Technique of Surgical Management in a Case of Acute on Chronic Type A and Type B Aortic Dissection

A 26-year-old male with Marfanoid features presented with severe interscapular pain. An ECG-gated CT aortogram (CTA) revealed acute dissection in the ascending aorta, and chronic dissection with complex tears, two false lumens, and a thrombus in the descending thoracic aorta (DTA) measuring 7.6 cm and involving the origin of the celiac artery. Tears were identified at the left subclavian artery (LSCA) origin and 4 cm distal to it. 

Transesophageal echocardiography (TEE) showed severe acute aortic regurgitation (AR). Cardiopulmonary bypass (CPB) was initiated using an 8 mm Gelweave graft anastomosed to the innominate artery with bicaval cannulation. The right femoral artery was cannulated, and the line was clamped prior. The aorta was clamped, and diastolic arrest was achieved via retrograde and ostia anterograde cardioplegia. The diseased proximal ascending aorta was excised. A 25 mm Chitra monoleaflet heart valve was selected and sutured to a 26 mm Intergard woven Dacron tube to create a valved conduit, which was then anastomosed to the aortic annulus with continuous 2-0 Prolene sutures. Both coronary buttons were anastomosed to openings in the Dacron tube using 5-0 prolene. Del Nido cardioplegia was administered again to check for leaks. 
 
The patient was cooled to 26°C, and lower body circulatory arrest was achieved while maintaining antegrade cerebral circulation through the graft in the brachiocephalic trunk and the left carotid artery under near-infrared spectroscopy (NIRS) monitoring. The diseased portion of the aorta beyond the LSCA was excised. The false lumen was obliterated using 4-0 Prolene sutures with a Teflon felt inside and was reinforced with a Teflon strip on the outside. A 26 mm Gelweave Plexus Dacron graft was anastomosed to the reinforced distal end, and lower body circulation was reestablished. 
 
The proximal and distal Dacron tubes were anastomosed, and clamped distal graft was removed, reestablishing coronary circulation. The LSCA was anastomosed to the distal side branch of the Plexus graft using a pericardial strip for hemostasis. After removing the cerebral perfusion cannula from the left common carotid artery (LCCA), the graft side branches were anastomosed to the LCCA and brachiocephalic trunk in order. The heart resumed beating in sinus rhythm, and the patient was successfully weaned from CPB. 
 
Postoperative CTA showed multiple tears with thrombus-containing false lumens in the DTA, extending to the celiac axis, with a maximum diameter of 7.6 cm. A follow-up surgery is planned to replace the DTA using a branch-first technique with an anastomosis between the celiac axis and the side branch. 

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