Discussion
In arch repair, the LSCA is deeply located, which makes it difficult to
visualize and therefore, creates technical challenges during surgical
repair in some patients. Therefore, several innovations have been
designed to facilitate the reconstruction of the LSCA, including direct
anastomosis, carotid-LSCA transposition or bypass, left axial
extra-anatomic bypass, and ligation without revascularization [1-2].
Direct end-to-end anastomosis is the simplest. However, anastomosis and
hemostasis are technically difficult in patients with deep LSCAs. The
LSCA easily retracts cranially following its transection. In contrast,
an extra-anatomic bypass of the left axial bypass through the left
thorax is used to avoid complex LSA anastomosis; however, it requires an
additional incision to expose the left axillary artery. This procedure
is time-consuming and is accompanied by the risk of brachial plexus
injury and wound infection [3]. Furthermore, postoperative adhesion
around the bypass in the left thorax can complicate future open surgery
via left thoracotomy for the enlarged descending aorta.
Our reconstruction technique provides excellent exposure of the LSCA by
pulling the origin of the LSAC caudally, which simplifies the
anastomosis. Hemostasis after reconstruction is feasible, as the
anastomosis in the anterior wall of the LSCA is easily visualized. The
disadvantage of our technique is the extension of total circulatory
arrest time which requires almost ten minutes.
The selection of patients for this technique is important, and it is
contraindicated in patients with dissected LSCA or LSCA with
atherosclerotic plaques, which can be repaired by the left axial
extra-anatomic bypass or fenestrated FET techniques [4].