59 First trifurcated frozen elephant trunk repair of an aortic arch aneurysm in Ireland. (6th October 2022)

• Record Type: Journal Article
• Authors: Khan, N; Young, V; Jahangeer, S
• Is Part Of: Heart. Volume 108(2022)Supplement 3
• Page Start: A53
• Page End: A53
• Publication Date: 2022-10-06
• Subjects: Heart -- Diseases -- Treatment -- Periodicals; Cardiology -- Periodicals; 616.12
• DOI: 10.1136/heartjnl-2022-ICS.59
• Languages: English
• ISSNs: 1355-6037

Abstract

Abstract : Introduction: We present the case of a 59 year old male with a complex aortic arch aneurysm on a background of open descending aorta replacement 11 years previously. An arch replacement was carried out using a trifurcated graft with frozen elephant trunk (FET) extension, representing the first use of such a graft in Ireland. Management Pre-operative CT showed a fusiform aortic arch aneurysm, 6.6cm in diameter, with extensive calcification and atheroma at the base of the left subclavian artery (LSA) ( figure 1 ). The repair was carried out via median sternotomy with cardiopulmonary bypass. Tri-cerebral perfusion (direct perfusion of all 3 epi-aortic vessels) was used during the arch repair. A large foley catheter was also placed into the descending aorta, under endoscopic guidance, to administer distal organ perfusion ( figure 2 ). The FET stent was deployed into the pre-existing descending aortic graft. The left common carotid and then the innominate arteries were anastomosed directly to the trifurcated graft, and an extra-anatomic bypass of the left subclavian artery (LSA) was finally performed. The procedure was tolerated well with no neurologic injury. Post-operative CT showed a satisfactory repair ( figure 1 ). Histology showed granulomatous aortitis. Discussion Increasingly sophisticated aortic grafts can provide solutions to challenging anatomy. The calcification and atheroma at the base of the LSA posed a potentially prohibitive risk of embolization during surgery. The trifurcated graft allowed a more proximal suture line in the aortic arch, thus avoiding dissection or suturing in this hostile territory. The use of a FET allowed complete repair of the aneurysm to the level of the previous graft, which more traditional methods may not have allowed. During arch surgery, organ protection plays a key role. Tri-cerebral perfusion allows for complete brain perfusion, irrespective of intracranial arterial anatomy. Conventional methods such as antegrade or retrograde cerebral perfusion may be hindered by lack of collaterals or presence of venous valves, respectively. The further addition of distal organ perfusion via a large Foley catheter allowed total body perfusion, maximising organ protection. The chosen sequence of anastomoses further minimised ischaemic time. Conclusion: Aortic arch surgery represents a challenging but evolving field in cardiac surgery, with considerable risk of mortality and neurological complications. Novel technology and techniques continue to facilitate safer, more complete repairs for this challenging group of diseases.