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Extraanatomical aortic bypass in aortic redo surgery
Konstadinos Plestis, MD, Oleg Orlov, MD, Ioannis Paralikas, MD, Alexander Uribe, MD
Lankenau Medical Center, Philadelphia, PA, USA.

OBJECTIVE: The use of extraanatomical aortic bypass in a complex aortic problem.
METHODS: A 43 year old female presented with severe chest pain and upper back pain. She underwent repair of type A aortic dissection with replacement of the ascending aorta and hemiarch in 2010. In October 2014 she had a left subclavian to carotid bypass followed by endovascular stenting of a large descending thoracic and arch dissecting aneurysm.
Upon admission a CT of the chest showed a large type 1b endoleak of the thoracic aortic endograft with an extensive periaortic hematoma throughout the descending aorta.
RESULTS: The patient underwent a combined median sternotomy and laparotomy The aorta was mobilized from the diaphragm to the iliac bifurcation. The patient was placed on cardiopulmonary bypass via a right subclavian and right atrium cannulation and was cooled to 18 C.
A 20 mm graft was anastomosed end-to-side with the infrareral aorta. Then the graft was passed underneath the transverse mesacolon and through the lesser sac into the right chest.
Under circulatory arrest and continuous antegrade cerebral perfusion a 12 by 8 bifurcation graft was used to connect to the left carotid and brachiocephalic artery.
The previously placed ascending graft was excised and replaced with a 26 mm graft because it was partially dehisced at the proximal anastomosis. The ascending graft was anastomosed to the 12 mm limb of the bifurcation graft end to end and to the 22 mm graft end to side. The supraceliac aorta was stapled closed. Cross clamp time was 62 min, circulatory arrest time was 5 min and total bypass time was 302 min.
Postoperatively she required prolonged ventilatory support. She also had an episode of transient paraparesis which was reversed completely by maintaining high blood pressure and utilizing a cerebrospinal fluid drainage. She was discharged home on postoperative day 18.
CONCLUSIONS: Extraanatomical aortic bypass can be extremely helpful in complex reoperative aortic surgery .

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