Extended replacement of aorta in chronic type A aortic dissection.

BACKGROUND

Chronic type A dissection is itself an indication for urgent surgery. Usually, replacement of the ascending aorta alone is adequate. Arch and descending aortas are replaced only in rare occasions-impending rupture, dilatation with diameter >5 cm. Extended replacement of the proximal aorta is associated with high morbidity and mortality. Staged repair is usually recommended by many centers. The disadvantages are the requirement for two stage operations, rupture of descending aorta in the interim period and patient denial to have the second stage. The authors use one stage operation in such patients.

PATIENT AND METHOD: A retrospective study of three patients who presented with chronic type A aortic dissection. Two patients were male and one was female, aged 65, 67 and 70 years old. All of them had a history of hypertension. One patient also had severe left main coronary stenosis and total occlusion of theright coronary artery. Clamshell incision was used for two patients and median sternotomy for one. Profound systemic hypothermia and circulatory arrest was used for replacement of the aortic arch first. Reperfusion of the brain was performed via a side graft to the main graft. And then proximal ascending aortic-graft anastomosis was performed, followed by descending aortic anastomosis. Distal coronary anastomoses were performed during the rewarming period followed by proximal anastomoses to the aortic grafts.

RESULTS

The circulatory arrest time was 38, 18 and 25 minutes. There was no reoperation for excessive post-operative hemorrhage. There was no lung contusion or injuries to left phrenic and left recurrent laryngeal nerve. All patients were alert and the time of endotracheal extubation was 16, 18 and 88 hours. One patient developed right pneumothorax after removal of the chest drain. Otherwise, all three patients survived without any complications.

CONCLUSION

In some patients who need extended replacement of proximal aorta, replacement of aortic arch first under circulatory arrest is a safe technique. Clamshell incision offers better exposure than median sternotomy. Because of the brief period of circulatory arrest, neurologic complications are rare.