A 62-year-old man, who developed an acute type A aortic dissection and underwent GR of the ascending aorta (J-Graft 24 mm; Japan Lifeline, Tokyo, Japan) 20 months before, presented with a relatively fast-growing distal aortic arch enlargement during a routine follow-up visit and was scheduled for admission followed by surgical treatment. However, he presented with a high fever while awaiting hospitalization and was admitted urgently to our hospital. On admission, his body temperature was elevated at 38.2 °C. The patient’s laboratory test results revealed the following: white blood cell count was within the normal range at 8.6 × 109/L, hemoglobin level was reduced at 6.5 mmol/L, serum creatinine level was within the normal range at 69.0 μmol/L, and C-reactive protein level was elevated at 115.4 mg/L. Transthoracic echocardiography indicated preserved cardiac function without vegetation. Computed tomography (CT) revealed a residual aortic dissection from the distal end of the vascular graft to the abdominal aorta; within 2 months, the maximum diameter of the distal aortic arch had rapidly expanded from 51 mm (Fig. 1a, b) to 64 mm (Fig. 1c, d). CT also confirmed a heterogeneous contrast effect in and around the false lumen of the dissecting distal aortic arch (Fig. 1c, d) without apparent systemic infection. We diagnosed a rapidly expanding dissecting aortic aneurysm (DAA) with the possibility of infection, and repeat surgery was scheduled urgently. However, the patient suddenly developed massive hemoptysis on the day preceding surgery and lost consciousness, resulting in cardiac arrest. Cardiopulmonary resuscitation (CPR) was immediately initiated, and percutaneous veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) was established via the femoral vessels; the return of spontaneous circulation was confirmed. Hemoptysis, which persisted during CPR, was controlled by combining VA-ECMO and mechanical ventilation with a high level (15 cm H2O) of positive end-expiratory pressure (PEEP). Thereafter, the patient’s hemodynamics stabilized, and he gradually regained consciousness without any apparent neurological dysfunction. The DAA was believed to have perforated the lungs; therefore, he was transferred to the operating room for emergency surgery.
Based on the preoperative CT scan, in addition to total arch replacement from the vascular graft anastomosed in the previous surgery, it was necessary, at least, to perform graft replacement of the proximal descending aorta (Fig. 1d). We simultaneously considered the possibility of the involvement of infection and the necessity for reliable hemostasis against hemoptysis. Therefore, preoperatively, we placed the patient in a slightly right lateral decubitus position (Fig. 2a) and performed a median sternotomy combined with a left thoracotomy using a straight incision with a rib-cross (SIRC) approach [4] (Fig. 2b, c) to manage the strong adhesions in the mediastinum and the left thoracic cavity; establish intraoperative organ protection, particularly for the myocardium and the brain; and secure a sufficient surgical field required for the extended thoracic aortic surgery. In addition to the division of the fourth to sixth ribs by the SIRC approach, an additional division from the eighth to tenth costal cartilages enabled us to secure an adequate surgical field despite strong adhesions in the thoracic cavity. The left lung was firmly adhered to the aorta, from the aortic arch to the descending aorta, and could not be separated from the proximal descending aorta. Meanwhile, the adhesion between the distal descending aorta and the left lung was relatively mild, which led to the decision of performing total arch and descending thoracic aortic replacement. The distal aortic arch was markedly dilated, and the bifurcation of the left subclavian artery was relatively deep; therefore, we decided to bypass to left axillary artery (AxA), anastomosed a vascular graft (J-Graft 9 mm; Japan Lifeline, Tokyo, Japan) to the left AxA, and temporarily clamped the proximal side of the vascular graft. Thereafter, we established an extracorporeal circuit (ECC) by incorporating this vascular graft as one of the arterial lines into the VA-ECMO system, in addition to the superior vena cava drainage and left ventricular venting.
Subsequently, we commenced gradual core cooling. Following the establishment of hypothermic circulatory arrest (urinary bladder temperature: 25.0 °C) and selective antegrade cerebral perfusion using the vascular graft anastomosed to the left AxA, we removed the flaps in the distal aortic arch, the thrombi in the false lumen, and any tissues with suspected infections. During this procedure, a 3 × 3 cm area of the lung parenchyma and pulmonary vessels were unexpectedly exposed. The area was believed to be related to the APF, which we directly closed as far as possible; there were no apparent signs of infection, including abscess formation. Although we successfully removed the APF, due to the inevitable iatrogenic lung injury, there was concern about the de novo development of extrapulmonary or airway hemorrhages. Therefore, we exposed the upper, middle, and lower branches of the pulmonary artery in the left hilar region in case ligation of the pulmonary arteries was required to control any hemorrhaging. After clamping the descending aorta at the T9 level, we resumed femoral artery perfusion (2 L/min) and ligated the intercostal arteries. Subsequently, we anastomosed a four-branched vascular graft (J-Graft 24 mm; Japan Lifeline, Tokyo, Japan) to the descending aorta using an open distal anastomosis technique while temporarily stopping femoral artery perfusion. Thereafter we started rewarming the patient. After a proximal anastomosis to the vascular graft of the ascending aorta and the reconstruction of the brachiocephalic artery, left carotid artery, and left AxA were performed, we started weaning the patient off the ECC.
As expected, a large amount of airway bleeding was confirmed in the left lung’s tracheal tube. Therefore, we ligated the upper branch of the pulmonary artery while observing the inside of the trachea using a bronchoscope. This temporarily reduced the bleeding; however, as airway bleeding recurred, ligation of the middle branch of the pulmonary artery was performed to suppress it. Thereafter, the patient’s hemodynamics and oxygenation were stabilized without VA or veno-venous ECMO support, and the operation was completed.
The patient was extubated on postoperative day 1. There was no infection, which was confirmed by the negative results of the preoperative blood cultures and the tissues collected during surgery. The patient developed mediastinitis 5 weeks postoperatively, but omentopexy combined with antibiotic therapies sufficiently controlled the condition. The patient was eventually discharged 16 weeks postoperatively without any neurological or respiratory dysfunction. Postoperative 3D CT showed that the aortic arch aneurysm was completely resected (Fig. 3). The patient remained in good health for the following 2 years.
