Total Arch Replacement with Stented Elephant Trunk in DeBakey Type I Acute Aortic Dissection
A 67-year-old female patient visited the hospital for acute DeBakey type I aortic dissection surgery. She had been admitted to another hospital for sudden chest pain 4 days earlier. Echocardiography showed 25% ejection fraction with a right ventricular wall motion abnormality, and the blood tests revealed creatine kinase-MB (CK-MB) at 220 mcg/L. For treatment of the acute myocardial infarct, the patient underwent emergency coronary stent insertion into the proximal right coronary artery (RCA) stenosis lesion, which revascularized after the procedure (). At that time, the cause of the chest pain was thought to be acute myocardial infarction (MI), but echocardiography and angiography showed the aortic dilatation, which was suggestive of the membrane of aortic dissection, and computed tomography (CT) was performed, which revealed acute DeBakey type I aortic dissection from the ascending aorta to the suprarenal artery. The MI appeared to be associated with acute DeBakey type I aortic dissection involving the proximal RCA (), and the ascending aorta and the descending aorta measured 52.0 and 30.8 mm in diameter, respectively. The right renal artery originated from the true lumen, and the left renal artery originated from the false lumen ().\nThe EF improved to 51% on echocardiography 2 days after coronary stent insertion. The patient was then transferred to Gangnam Severance Hospital, Yonsei University Health System. Upon admission, the patient was intubated for mechanical ventilator support and her vital signs were stable. We could not verify her consciousness level. However, there was a definite pupil reflex response, and CK-MB was at 13.35 mcg/L. We decided to perform the operation. A median sternotomy was performed, and dual cannulation was performed at the left femoral artery and the right axillary artery, which was anastomosed with an 8 mm vascular graft. After venous cannulation of the right atrium, cardio-pulmonary bypass (CPB) was started. The rectal temperature decreased to 26.4℃ during aortic dissection. When we open the aorta after unilateral SCP, there was a big intimal tear at the distal ascending aorta. The aortic arch and the branches of the aorta were removed with the patient in a low temperature state with antegrade selective cerebral perfusion (SCP). We inserted a SET with a 32 mm diameter, and 20 cm length (5+15; S&G Biotech Inc., Seongnam, Korea) to the descending aorta 1 to 2 cm posterior of the left subclavian artery through the introducer. During the operation, through trans-esophageal echocardiography, the distal stented graft was traced. Total aortic arch graft replacement was then performed with a 30 mm 4-branch graft. The CPB time was 190 minutes, the aortic cross-clamping time was 69 minutes, the total cardiac arrest time was 50 minutes, and the SCP time was 20 minutes. The patient's postoperative state was stable, and she was followed up with CT. The patient regained consciousness without any neurological problems ().