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J Cardiothorac Surg
J Cardiothorac Surg
Journal of Cardiothoracic Surgery
1749-8090
BioMed Central London

3031
10.1186/s13019-024-03031-z
Case Report
Extensive aortic replacement including aortic arch for a mega aorta with chronic aortic dissection via posterolateral thoracotomy
Ikeda Shinichiro ifkieg13@gmail.com

Yoshitake Akihiro
Kumagai Yu
Oki Naohiko
Hori Yuto
Gyoten Takayuki
Kinoshita Osamu
Tokunaga Chiho
Asakura Toshihisa
grid.412377.4 0000 0004 0372 168X Department of Cardiovascular Surgery, Saitama Medical University International Medical Center, Hidaka city, Saitama prefecture Japan
9 9 2024
9 9 2024
2024
19 5193 5 2024
30 8 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Background

Mega-aortic syndrome including aortic arch and descending aortic aneurysm is a challenging surgical case. Because the aorta continuously dilates, creating the distal anastomosis sites becomes an issue. Despite the developments in endovascular techniques including frozen elephant trunk, in the case of mega-aortic syndrome or mycotic aneurysm, extensive surgical repair is still a strong armamentarium. Our patient had a mega-aorta with chronic aortic dissection. Herein, we show tips regarding concurrent ascending, aortic arch, and descending aortic replacement via posterolateral thoracotomy for this relatively young patient.

Case presentation

A 46-year-old man with chronic kidney disease had chronic type A aortic dissection with an extensively dilated thoracic aorta from the distal ascending to the descending aorta measuring 63 mm in diameter and abdominal aorta measuring 50 mm. The short segment of the distal descending aorta was narrowed to 36 mm. The patient underwent a concurrent replacement of the distal ascending aorta, aortic arch, and descending aorta via a posterolateral thoracotomy. The patient was extubated on postoperative day (POD) 1 and discharged home without serious complications such as stroke, respiratory failure, or renal failure on POD 18. The 1-year follow-up computed tomography did not find issues in the anastomosis sites; however, the abdominal aorta enlarged from 50 to 58 mm. The patient underwent a thoracoabdominal aortic replacement and recovered well without any complications.

Conclusions

Good exposure and meticulous organ protection methods are key to a safe concurrent replacement of the ascending, aortic arch, and descending aorta via posterolateral thoracotomy.

Keywords

Mega-aorta
Extensive thoracic-aortic replacement
Posterolateral thoracotomy
No fundingissue-copyright-statement© BioMed Central Ltd., part of Springer Nature 2024
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pmcBackground

A mega-aorta is relatively rare and a challenging surgical case. Various treatment options have been proposed for this pathology including endovascular techniques including frozen elephant trunk and fenestrated stent graft; however, the definite treatment guideline has not been established yet. Because a mega-aortic syndrome is not commonly encountered, an open repair requires some experience [1]. Herein, we show the technical details of concurrent ascending, aortic arch, and descending aortic replacement via posterolateral thoracotomy for a relatively young patient with a mega-aorta. Our technique included antegrade cardioplegia, selective antegrade cerebral perfusion (SACP), and lower body perfusion from the femoral artery during distal anastomosis. Good exposure of the aorta and meticulous organ-protection methods are the key to this operation.

Case presentation

A 46-year-old man with a history of chronic kidney disease was incidentally diagnosed with chronic type A aortic dissection and aneurysm during a preoperative examination for an inguinal hernia. His blood test was normal, except for creatinine of 1.44 mg/dL (estimated glomerular filtration rate: 43.4 mL/min/1.73 m2). Preoperative echocardiography showed a 79% ejection fraction and the absence of significant valvular disease. Computed tomography (CT) revealed a type A aortic dissection extending from the distal ascending aorta to the iliac arteries. The aortic root was 44 mm in diameter, and the proximal ascending aorta was 35 mm and not dissected. The distal ascending aorta and arch were dilated to 66 mm [true lumen (TL), 11 mm; false lumen (FL), 55 mm], and the descending aorta was 63 mm (TL, 11 mm; FL, 52 mm). The size of the distal descending aorta decreased to 36 mm (TL, 9 mm; FL, 27 mm), and the abdominal aorta dilated to 50 mm (TL, 10 mm; FL, 40 mm) (Fig. 1A–D). The Adamkiewicz artery was identified at the level of Th8 (Fig. 1E). A replacement of the aneurysm part from the nondissected part of the distal ascending aorta to the level of Th9 of the distal descending aorta measuring 36 mm was performed.

Fig. 1 Preoperative and postoperative computed tomography scans. A–D. Aortic dissection from the distal ascending aorta to the iliac artery. The aorta was extensively dilated, with an aortic arch measuring 66 mm; descending aorta, 63 mm; and abdominal aorta at the level of the celiac artery, 50 mm. The distal descending aorta was 36 mm. E. The Adamkiewicz artery was identified at the Th8 level. F. The 1-year follow-up CT showed the aorta, from its distal ascending segment to its distal descending part (Th9 level) replaced with a graft. No anastomosis issue such as pseudoaneurysm was observed. The abdominal aorta at the level of the celiac artery grew to 58 mm

Procedure

Under general anesthesia, the patient was intubated with a double-lumen tube for one-lung ventilation. Arterial lines were placed in both radial arteries and left dorsalis pedis arteries. Cerebral oximetry and motor-evoked potentials were monitored intraoperatively. With the patient in the right lateral decubitus position, a thoracotomy skin incision was made from the nipple line to the tip of the scapula. The left internal mammary artery was preserved. Furthermore, the intercostal space was opened. The distal fourth and proximal fifth ribs were separated for enhanced exposure (Fig. 2A). After systemic heparinization, venous and arterial cannulas were inserted through the left femoral vein and artery, and cardiopulmonary bypass and systemic cooling were initiated. The pericardium was opened to expose the heart and ascending aorta. The left upper pulmonary vein was identified outside of the pericardium, and a left ventricular (LV) vent catheter was inserted into the left atrium via the left upper pulmonary vein and advanced downward into the left ventricle (Fig. 2B). The position of the cannula was confirmed in the left ventricle by transesophageal echocardiography. The ascending aorta was cross-clamped to induce antegrade cardioplegia via a root cannula (Fig. 3A). Upper body circulatory arrest was undertaken at a bladder temperature of 25℃. The mid-descending aorta (Th7 level) was clamped to ensure lower body perfusion from the femoral artery cannula. Balloon-tipped cannulas (15-, 12-, and 12-Fr cannulas, Sumitomo Bakelite Akita, Japan) were placed into the arch branch vessels for SACP at 12 mL/kg. All arch branches were snared during SACP. A traction suture on the side of the pulmonary artery provided better exposure of the ascending aorta (Fig. 3B). A four-branched graft (J graft 26-mm four-branched, Japan Lifeline, Tokyo, Japan) was anastomosed to the non-dissected distal part of the ascending aorta with a thick felt and 4 − 0 Nespiren (Alfresa Pharma Corporation, Osaka, Japan) continuous suture. A root vent was placed on the graft for de-airing, and rewarming was initiated. The arch branch vessels were individually anastomosed to the graft branches (Fig. 4A). The Adamkiewicz artery was reconstructed using a 10-mm graft, which was attached to the main graft. Anastomosis of the distal descending aorta was performed at the Th9 level with a thick felt and 4 − 0 Nespiren continuous suture (Alfresa Pharma Corporation). The distal anastomosis site was wrapped with a Gore sheet for future thoracoabdominal repair. The heart was de-aired via the root and LV vent and weaned from cardiopulmonary bypass (Fig. 4B). The operative time was 569 min, which included 227 min of cardiopulmonary bypass, 62 min of cross-clamping, and 78 min of selective antegrade cerebral perfusion. Postoperatively, the patient was extubated on POD 1 and transferred to a step-down unit from the intensive care unit on POD 2. The left chest tube kept draining 200–300 mL/day even though the fluid was not from chylothorax. On POD 14, the chest tube was finally removed. He was discharged home without serious complications, such as neurological deficit, renal failure, or respiratory failure on postoperative day 18. The 1-year postoperative follow-up contrast-enhanced CT showed the aorta, from its distal ascending segment to the distal descending part (Th9 level) replaced with a graft. No anastomosis issues such as pseudoaneurysms were found; however, the thoracoabdominal aneurysm grew from 50 mm at the index surgery to 58 mm (Fig. 1F). The patient underwent thoracoabdominal aortic replacement with a 24-mm thoracoabdominal graft (J-graft 24-mm thoracoabdominal graft, Japan Lifeline) from the previous graft to the bilateral common iliac artery. The patients recovered well without any complications.

Fig. 2 Intraoperative views (from the surgeon’s view on the patient’s left side). A. A thoracotomy skin incision was made from the nipple line to the tip of the scapula. The distal fourth rib and proximal fifth rib were separated. B. A left ventricular vent was inserted via the left upper pulmonary vein

Fig. 3 Intraoperative views (from the surgeon’s view on the patient’s left side). (A) The ascending aorta was cross-clamped to induce antegrade cardioplegia. Moreover, 15-, 12-, and 12-Fr balloon-tipped cannulas were placed into the arch vessels for selective antegrade cerebral perfusion. (B) A traction suture on the right side of the pulmonary artery provided good exposure of the ascending aorta

Fig. 4 Intraoperative views (from the surgeon’s view on the patient’s left side). A. The brachiocephalic artery was anastomosed to one of the graft branches. B. The aorta, from its distal ascending segment to the distal descending part (Th9 level), was replaced with a four-branched graft

Discussion and conclusions

A mega-aortic syndrome is associated with clinical challenges as the aorta extensively dilates. This characteristic makes it difficult to create a distal anastomosis site or a landing zone for endovascular treatment [1]. In addition, our patient had a chronic dissection, and the TL was small (11 mm) in the descending aorta and abdominal aorta. In the current era, an endovascular technique has been developed; however, it is challenging for cases with a small TL, and are associated with device-related complications such as endoleaks and may not be appropriate for younger patients [1–6]. An open-repair approach via median sternotomy is total arch replacement with an elephant trunk or frozen elephant trunk for the first stage, followed by descending aortic replacement and thoracoabdominal aortic replacement. In our case, the aorta continuously dilated from the distal arch to the short segment of a narrowed portion (36 mm) in the distal descending aorta. In this case, distal anastomosis from a median sternotomy appears challenging. A Terumo Siena four-branched collared graft (Terumo, Somerset, NJ) has a collar on the distal side, so distal anastomosis is possible even at a large caliber site; however, aortic rupture during the interval period is also a concern [7, 8]. Compared with total arch replacement via median sternotomy, posterolateral thoracotomy approach is more protective of lower body organs including the kidney. Because cross-clamping the descending aorta was possible, lower-body perfusion can be maintained. Posterolateral thoracotomy may be more beneficial, particularly in patients who have chronic kidney dysfunction. Concerning extensive thoracic aortic replacement, different approaches such as a clamshell, anterolateral, and posterolateral thoracotomies may be performed [9–12]. Posterolateral thoracotomy does not require dividing the sternum, and the wound might be more stable than others. Sternal dehiscence is a well-known complication of clamshell thoracotomy. Posterolateral thoracotomy has been reported with excellent outcomes in some institutes; however, mega-aortic syndrome cases are scarce even in a high-volume center [10, 11]. Despite excellent results by experts’ hands, this approach is complex and not a routine procedure. To treat mega-aortic syndrome and mycotic aneurysm including aorto-esophageal fistula or aorta-tracheal fistula, this approach is necessary. Herein, we present several tips for this procedure. First, good organ exposure is one of the key factors. Dividing the distal fourth rib and the proximal fifth rib provides a wider view of the ascending aorta, aortic arch, and descending aorta. Although the brachiocephalic artery is located deep in this surgical field, it is accessible from this incision for selective antegrade cerebral perfusion. If its exposure is not enough from this incision, extending the incision by dividing the sternum can be helpful. Setting a traction suture on the right side of the pulmonary artery provides a good view of the ascending aorta (Fig. 3B). When performing anastomosis of an arch vessel, an assistant arm (Terumo Cardiovascular, USA) helps open the space for the maneuver (Fig. 4A). In the case of atherosclerotic aorta and shaggy aorta, this approach may not be appropriate because of the high risk of stroke as further distal exposure of arch vessels is necessary to anastomose at the level of healthier caliber. Second, for myocardial protection, antegrade cardioplegia can be administered from the ascending aorta via either a root cannula in the ascending aorta, or a balloon-tipped catheter is inserted into the ascending aorta. The aortic root is deeply located, and debris or air enters the coronary arteries or the left ventricle. To prevent this, the ascending aorta was cross-clamped or the ascending aorta was occluded with a balloon-tipped catheter while dissecting aortic arch. Regarding the decompression and de-airing of the heart, a root cannula and an LV vent catheter were placed. A LV vent catheter is reported to be inserted via the apex of the heart or left atrial appendage [10–12]. We routinely inserted an LV vent catheter through the left pulmonary vein. An LV vent catheter was pushed into the atrium and pushed against the wall downward to the left ventricle. A left pulmonary vein is an easy-access site and has fewer complications. The apex of the heart insertion may cause pseudoaneurysms. Appropriate organ protection is important. When organ exposure is poor or concerns regarding proper organ protection have been raised, it is critical to not hesitate to either extend the incision or switch to more familiar approaches. This case highlights that we could safely perform extensive thoracic aneurysm repair via posterolateral thoracotomy with meticulous organ-protection methods.

Author contributions

Drafting the work: S.I.Revising the work: A.Y.Conception of the work: T.G., O.K., T.A., Y.K., N.O.,Y.H., C.T.

Funding

No funding.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Consent was obtained.

Consent for publication

was obtained.

Competing interests

The authors declare no competing interests.

Abbreviations

CT Computed tomography

Fl False lumen

LV Left ventricular

SACP Selective antegrade cerebral perfusion

TL True lumen

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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