Repair of Aortic Graft Aneurysm 20 Years After Extra-Anatomic Aorto-Aortic Bypass for Interrupted Aortic Arch

This video demonstrates a very rare case of the repair of an aortic graft aneurysm for a patient postaorto-aortic bypass for an interrupted aortic arch.

The patient was a 36-year-old woman with a known case of interrupted aortic arch. She had an aorto-aortic bypass graft when she was 16 years old through a right thoracotomy. She presented to ED with sudden right-sided chest pain. CXR and CT scan of the chest showed dilated aortic graft to 65 mm (previous size was 45 mm a year ago). She was stable and there was no evidence of leak.

Because of the progressive dilatation of the graft, the authors offered her repair through sternotomy and she accepted. The case was discussed in the authors’ surgical MDT meeting and they approved the plan. For CBP, they used right axillary artery and left femoral artery cannulation in addition to right atrium. The heart was arrested and protected with antegrade blood cold cardioplegia, in addition to cooling the patient.

Intra-op findings: The old tube graft was connected to the ascending aorta and running retro-pericardial on the right side and then posteriorly. There were a lot of adhesions around the graft; its proximal part was dilated and compressing on the right lung.

Technique: Sternotomy, pericardiotomy and cannulation were performed. While the main surgeon was standing on the left side of the patient, the right pericardium was retracted medially. Exposure of the graft was started by dissecting the pericardium and the surrounding tissues. After getting good access to the distal part of the graft, it was clamped just above the diaphragm. Another clamp was applied to the ascending aorta. More dissection was done to expose mainly both ends of the graft. The distal part of the graft was opened. Since the distal part of the graft was not dilated, a new tube graft was anastomosed to the remaining stump using proline 4/0 and re-enforced with bio glue. The distal clamp was removed and the new graft was de-aired. The proximal part of the old graft was totally separated from the ascending aorta. The length of the new graft was adjusted, then its proximal part was anastomosed to the ascending aorta. The proximal clamp was removed after adequate de-airing. Weaning from the pump and decannulation were done as routine. The patient had a smooth postoperative course. She was extubated on day 0, and discharged on day six.

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