Partial aortic root remodeling and reimplantation of patent saphenous vein grafts in a chronic type A dissection with aorto-left atrial fistula

S. Ohira
Westchester Medical Center, Valhalla, New York

Please explain the educational or technical point that this video addresses.: This patient had history of CABG a couple years ago and presented with diagnosis of chronic DeBakey II aortic dissection and aorto-left atrial fistula with patent bypass grafts (LIMA-LAD, SVG-OM, SVG-PDA). Primary entry was observed right next to the vein to PDA graft. In this case, partial aortic root remodeling, hemiarch replacement, closure of aorta-left atrial fistula, and reimplantation of saphenous vein grafts was performed. One of the vein graft to OM branch was reimplanted using Carrel patch technique and the other vein graft to PDA was reimplanted using hemi-Cabrol or Piehler technique. This case highlights several important techniques to treat complex case such as partial aortic root remodeling in complex dissection, how to reimplant patent vein grafts, and how to determine the location of proximal SVG graft anastomoses.

Please provide a 250 word summary of the surgical video being submitted.: This patient was an early 70 year old male with a past medical history of triple vessel CABG a year ago who then presented with chest pain and shortness of breath. Echocardiography and computed tomography showed DeBakey type 2 aortic dissection and aorto-left atrial fistula with patent bypass grafts (left internal mammary artery [LIMA] and vein grafts [SVG]). The patient developed pulmonary edema, which required intubation, and acute kidney injury. The right axillary artery was directly cannulated. After the ascending aorta and LIMA were clamped, the aorta was transected while leaving an aortic tissue around the two SVG grafts. An entry tear was found right next to the proximal anastomosis of SVG to the PDA. There was an approximately 1x2 cm fistula between a false lumen in the non-coronary sinus (NCC) and the dome of the left atrium. This fistula was closed with running 4-0 polypropylene suture. Since the adventitia was thinned out in the NCC sinus as a result of chronic dissection, proximal aortic root repair was performed using the partial remodeling technique and resuspension of commissures where the 26 mm Dacron graft was fashioned by creating a tongue portion corresponding to NCC sinus. Distal anastomosis was performed under moderate hypothermia and unilateral antegrade cerebral perfusion. After systemic perfusion was resumed, location of the SVG buttons was determined. Ascending graft was cross-clamped again; SVG to obtuse marginal branch graft was reimplanted using Carrel patch technique while SVG to the PDA required interposition of 10 mm Dacron graft.