Case presentation
An 83-year-old man presented with a KD and right ASA originating from the descending aorta as the fourth supra-aortic branch passing behind the trachea and esophagus. The KD measured 21 mm. Additionally, he had an 83-mm thoracic saccular aneurysm on the aortic arch and a 45-mm saccular aneurysm on the descending aorta (Figure 1).
We planned a two staged hybrid procedure using a total arch replacement (TAR) with a frozen elephant trunk (FET) and distal extension of the thoracic endovascular aortic repair (TEVAR).
The patient underwent a TAR using the FET technique performed through a median full sternotomy. Initially, 9 mm tubular grafts (J Graft Japan Lifeline Co, Ltd, Tokyo, Japan) were anastomosed to both the left and right axillar arteries in their second portion. After systemic heparinization, an arterial cannula was inserted from the ascending aorta, and venous cannulas were placed through the superior and inferior vena cavae. Subsequently, cardiopulmonary bypass (CPB) was instituted. The right ASA was exposed just at the right side of the main bronchus with the guidance of preoperative CT.
As the core temperature fell to 30 °C, under circulatory arrest, the right ASA was ligated at the previous dissected part. After the left subclavian artery was ligated at its origin, antegrade selective cerebral perfusion (SCP) was initiated through both of the 9 mm graft conduits anastomosed to both axillar arteries. Twelve-Fr balloon-tipped cannulas were inserted into both common carotid arteries. The antegrade SCP flow was maintained at 10 to 12 ml/kg/min using an independent roller pump, and the balloon tip pressure was maintained between 30 and 40 mmHg.
The aortic arch was transected between the left common carotid and left subclavian artery, and a 31 -120 mm FET (J graft FROZENIX Japan Lifeline Co, Ltd, Tokyo, Japan) was inserted with direct vision without fluoroscopy or trans-esophageal echocardiography. After deploying the FET, a stump of the graft was anastomosed to the four-branched graft (J Graft Japan Lifeline Co, Ltd, Tokyo, Japan) by a 3-0 polypropylene running suture. The lower body circulation was reinstituted through a branch graft. The proximal anastomosis with a 3-0 polypropylene running suture was then accomplished, followed by coronary reperfusion. The first branch was anastomosed to the right carotid artery and the second to the left carotid artery by a 4-0 polypropylene running suture. A 9-mm tubular graft from the right subclavian artery was anastomosed to the first side branch using an end-to-side anastomosis. Finally, another 9-mm tubular graft from the left subclavian artery was anastomosed to the ascending tubular graft in an end-to-side fashion. The durations of the operation, extracorporeal circulation, aortic cross-clamping, and circulatory arrest were 391, 185, 95, and 74 minutes, respectively. Postoperative CT revealed good patency of the bypass graft to the supra-aortic vessels and complete exclusion of any KD or saccular aneurysm by the FET (Figure 2).
Three weeks after the TAR with an FET, a scheduled TEVAR was performed. A stent graft (Gore CTAG 26 mm × 200 mm Gore & Associates, Flagstaff, AZ, USA) was deployed in the lower descending aorta in a retrograde fashion through a left femoral access. Subsequently, the second stent graft (Gore CTAG 31 mm × 200 mm Gore & Associates, Flagstaff, AZ, USA) was additionally inserted as a bridging of the previously placed FET and first stent graft.
The patient’s recovery was uneventful. The postoperative CT showed the complete exclusion of both aneurysms and KD by the stent graft (Figure 3). He was discharged from the hospital 10 days after the surgery without any complications.