A 73-year-old man with a history of smoking and hypertension was admitted to his referring hospital with chest pain and dyspnea. Computed tomography (CT) revealed a penetrating atherosclerotic ulcer (PAU) with intramural hematoma in the distal part of the aortic arch and left hemothorax. Antihypertensive therapy was promptly instituted. A bypass between the left and right carotid arteries was performed and the intimal ulcer was covered by the stent-graft (Zenith Cook 36 mm) in supra-subclavian landing zones; its exclusion was confirmed by the postoperative angiography.
The postoperative course was uneventful and the patient was discharged home on postoperative day 8.
Three months after his discharge, the onset of nausea and hemoptysis required emergent hospitalization.
CT scan showed a retro-A dissection with partially thrombosed false lumen in ascending aorta [Figure 1], extravasation of contrast into perigraft space with a big periaortic hematoma in the area of the distal portion of the stent graft [Figure 2], left apical lung hemorrhage and hemothorax.
The patient was referred to our hospital for an emergent surgical approach.
The operation was performed with a single-stage approach via bilateral anterior thoracosternotomy. Cardiopulmonary bypass was established using the right axillary artery and right atrium. A clamp was placed on the distal ascending aorta and the ascending aorta was incised. No entry tear was found; the false lumen was partially thrombosed. Cold intermittent blood cardioplegia was delivered antegradely. Once the aortic valve was resuspended and proximal anastomosis was performed with a 30 mm Dacron graft (Hemashield Gold; Boston Scientific Medi-Tech. Wayne, NJ, USA), cooling was initiated in case of circulatory arrest. Once a deep hypothermia (20° C) was reached, brachiocephalic trunk, the left common carotid artery and the descending aorta at level of the diaphragm were clamped and a modified cardiopulmonary bypass was performed starting the flow also through a second femoral artery line. After the left phrenic and left vagus nerves were identified, the aortic arch and the descending aorta were incised and the stent graft was removed. After the completion of the distal anastomosis with a Dacron graft (Hemashield Gold 26 mm), the two grafts were end-to-end sutured. The distal clamp was removed and coronary perfusion was reestablished through the femoral artery line. Perfusate flow was increased and rewarming was initiated. A 20 × 10 mm bifurcated Dacron graft was anastomosed in an end-to-side fashion to the ascending aorta, the brachiocephalic trunk, and the left common carotid artery. Antegrade cardiopulmonary bypass was restarted [Figure 3].
The postoperative period was uneventful excepted for the presence of prolonged pulmonary air leakage. The patient was discharged on postoperative day 35. At 3 month follow up, a contrast-enhanced thoracic CT showed the image of a pseudoaneurysm with a maximum diameter of 75 mm developed at the level of the distal anastomosis. The patient underwent aortic stent grafting (William Cook Europe) without complications.
At 2 years follow up a CT showed the occlusion of the by-pass between the two carotids [Figure 4]. At this time, the patient was in optimal state of health and no neurological episodes were reported.