AN ALTERNATIVE APPROACH TO A TYPE A DISSECTION OF A PARTIAL PORCELAN AORTA WITH SEVERE AORTIC INSUFFICIENCY AND CONCOMITANT CORONARY DISEASE
Demetrius Protogeros, Aristeidis Argyroulis.
HENRY DYNANT HOSPITAL ATHENS GREECE, Athens, Greece.
INTODUCTION:Treatment of Type A aortic dissection represents one of the most technically challenging surgical procedures. Time remains the limiting factor for every surgical treatment which has to be executed urgently and within an experienced environment. For all types of dissections of the ascending thoracic aorta, accommodated procedures have been described, providing an arsenal of solutions to the different types of pathology to be confronted with. We present an innovative, alternative treatment approach, adapted to a specific pathological environmentCASE PRESENTATION:A 74 yo female patient with an acute type A aortic dissection was referred for surgical treatment. Comorbidities included chronic end stage renal insufficiency under hemodialysis, peripheral artery disease, coronary disease, previous PTCA of the right Iliofemoral artery. She had a cardiac pacemaker and was on anti-vitamin K medication due to chronic atrial fibrillation. The aneurysm of the ascending aorta and coronary artery disease were diagnosed two years prior to the dissection incident. Following the confirmation of the diagnosis, she deteriorated rapidly due to the development of hemopericardium, leading to the emergency transfer of the patient to the operating theater under cardiopulmonary resuscitation.PROCEDURE:Because of an extensively calcified, porcelain aorta and after establishing emergency cardiopulmonary bypass via the right femoral artery and the right atrium, our surgical procedure was the following:-local endoluminal plastic reconstruction of the dissected aortic root with multiple pledgeted interrupted sutures and surgical bio-glue, due to the inability to safely remove and replace t the heavily calcified aortic wall-Plastic repair of the aortic valve according to the Cabrol method-Composite Arterio-Venous Coronary arterial grafting, with the use of a saphenous vein extension on a pedicled right internal thoracic artery, to the left anterior descending coronary arteryOUTCOME:Despite the patients hemodynamic instability preoperatively and the technical challenges of the repair, successful weaning from cardiopulmonary bypass was achieved after 176 min. The patient was transferred to the ICU hemodynamically stable and extubated after 12 hours. Following a control CTA the patient was discharged on the 7th postoperative day.
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