1.2 Surgical procedure
The patient was transferred immediately to the operating room. During
induction of anesthesia, the patient’s blood pressure dropped to 55/35
mmHg. Median sternotomy and pericardiostomy were performed immediately.
A massive hematoma was removed, improving the patient’s hemodynamic
status. Careful inspection revealed no active bleeding from the aorta.
Exploratory laparotomy showed extensive bowel ischemia, recognized by
intestinal pallor, absence of peristaltic movement, and loss of
pulsation of the main trunk and branches of the SMA. To prevent
progression to irreversible bowel damage, SMA-left external iliac artery
bypass was performed by application of a saphenous vein graft. After
revascularization of the SMA, mesenteric perfusion quickly improved, as
evidenced by pulsation of the intestinal arteries and peristalsis.
Cardiopulmonary bypass (CPB) was then established by cannulation of the
right femoral artery and the superior and inferior vena cava and
placement of a left ventricular venting tube via the right upper
pulmonary vein. The patient was cooled to
21.9°C,
and the dissected ascending aorta was excised. The primary entry tear
was resected, and open distal hemiarch replacement was performed. There
were no further signs of mesenteric malperfusion during the surgery. The
abdomen was closed on postoperative day (POD) 1, and the patient was
extubated on POD 2. The postoperative course was uneventful, and CT
performed on POD 7 showed an expanded true lumen, opened side branches
of the abdominal aorta, and patency of the venous graft. The patient was
discharged complication free on POD 20. CT performed 8 months after the
surgery revealed a patent venous graft (Figure 2). Twelve months have
passed since the surgery, and the patient remains healthy.