Operative Repair of Aortic Dissection with an Entry Tear on the Lesser Curve of the Arch

After more than six hours in an emergency department, a seventy-one-year-old male was diagnosed with acute aortic dissection. He was transported by helicopter and taken directly to the operating room in shock (lactate 4.4mmol/L) with hemopericardium. The dissection extended from the sinus portion of the aorta to the distal arch.  

An 8mm graft was sewn to the innominate artery for arterial inflow for cardiopulmonary bypass (CPB). 

The pericardium was then marsupialized, and the right atrium was cannulated for venous return. CBP was established with cooling to 28°C, during which period the ascending aorta was then mobilized and the left common carotid artery isolated. During circulatory arrest, with bilateral antegrade cerebral perfusion, the ascending aorta and proximal arch were removed by dividing the aorta distally from the origin of the innominate artery to the midpoint of the lesser curve and then proximally just above the sinotubular junction. A large entry tear was apparent on the lesser curve of the arch, and so an extended resection of the lesser curve was necessary. An open distal hemi-arch-to-graft anastomosis was completed, and then CPB was resumed with rewarming. 

The proximal aorta was then addressed by interposing felt and biological glue between the dissected medial layer, primarily in the noncoronary sinus, and then suspending the aortic valve at its three commissural posts. After tapering the graft and completing the proximal anastomosis, the graft clamp was released. 

After deairing, CPB was weaned off and hemostasis achieved. The patient spent two nights in the ICU, four on the ward, and was discharged without complications. In aortic clinic three months later, he was well. 

References

1. Trimarchi S, de Beaufort HWL, Tolenaar JL, Bavaria JE, Desai ND, Eusanio MD, Bartolomeo RD, Peterson MD, Ehrlich M, Evangelista A, Montgomery DG, Myrmel T, Hughes GC, Appoo JJ, Vincentiis CD, Yan TD, Nienaber CA, Isselbacher EM, Deeb GM, Gleason TG, Patel HJ, Sundt TM, Eagle KA. Acute aortic dissections with entry tear in the arch: a report from the International Registry of Acute Aortic Dissection. J Thorac Cardiovasc Surg 2019; 157: 66-73
2. Roberts CS, Roberts WC. Aortic dissection with the entrance tear in transverse aorta: analysis of 12 autopsy patients. Ann Thorac Surg 1990: 50: 762-6

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