International Society For Minimally Invasive Cardiothoracic Surgery

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Total Arch Replacement With Frozen Elephant Trunk In Right Aortic Arch Patients With Kommerell's Diverticulum
Yosuke Takahashi, Takashi Murakami, Hiromichi Fujii, Akimasa Morisaki, Shinsuke Nishimura, Yoshito Sakon, Kokoro Yamane, Toshihiko Shibata.
Osaka City University Graduate School of Medicine, Osaka, Japan.

OBJECTIVE: Open stent graft insertion and positioning in right aortic arch patients with Kommerellís diverticulum can be challenging. We report a case of successful total arch replacement via the frozen elephant trunk procedure using a pull-through technique.
METHODS: A 66-year-old man was diagnosed with a right aortic arch and Kommerellís diverticulum. The diverticulum diameter measured up to 61 mm. Enhanced computed tomography (CT) showed that the first artery in the neck was the left carotid, the second was the right carotid, the third was the right subclavian, and the fourth was the left subclavian. The case was complicated by a shaggy aorta, extending from the ascending to the abdominal aorta. Surgery was performed via median sternotomy. First, the left subclavian artery was exposed and an anastomosis was made with an 8-mm prosthetic graft. Cardiopulmonary bypass was initially established with ascending aortic cannulation and venous return from the right atrium. Under circulatory arrest and selective antegrade cerebral perfusion at a cranial temperature of 25įC, we trimmed the aorta at the predetermined line between the right subclavian and left subclavian arteries. An open stent graft was inserted in the descending aorta using a pull-through technique. Distal anastomosis was made with a 4-branched graft. Reconstruction of the right subclavian and right carotid arteries was performed. Proximal anastomosis of the aorta was performed. After decamping of the aorta, reconstruction of the left carotid and left subclavian arteries was performed. Finally, plug insertion of the left subclavian artery was performed to prevent a Type II endoleak.
RESULTS: Aortic cross-clamp and circulatory arrest times were 138 minutes and 80 minutes, respectively. The distal end of the stent was at the Th 8 level. There were no postoperative complications. Postoperative CT did not show a Type I or II endoleak, and complete thrombosis of the aneurysm was achieved.
CONCLUSIONS: The frozen elephant trunk procedure using the pull-through technique enables reliable and secure insertion of stent grafts in right aortic arch patients with Kommerellís diverticulum.


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