Surgical Technique
A 70-year-old woman was diagnosed with chronic aortic dissection. Contrast-enhanced computed tomography (CT) demonstrated a type A aortic dissection with a primary intimal tear in the ascending aorta. The aortic diameters were 76mm in the ascending aorta and 74mm in the descending aorta (Figure 1).
Elective surgery was performed via a median sternotomy. Cardiopulmonary bypass was initiated via cannulation of the ascending aorta, right atrium, and left ventricular vent. Hypothermic circulatory arrest was induced at a rectal temperature of 25°C. Retrograde and antegrade cold blood cardioplegia were administered intermittently. Antegrade cerebral perfusion was injected into the three supra-aortic vessels. LSCA reconstruction was performed before the distal anastomosis. First, the origin of the LSCA was ligated by silk threads, which were then pulled caudally for better exposure of the LSCA. By clamping the distal LSCA, the anterior wall of the LSCA was incised longitudinally. Subsequently, a 5-cm length graft, which formed a part of the 4-branched Dacron tube graft (J graft Japan; Lifeline, Tokyo, Japan), was anastomosed to the LSCA using 5-0 polypropylene sutures (Figure 2-a). The LSCA was declamped, and antegrade cerebral perfusion to the LSCA was ensured through the anastomosed graft (Figure 2-b).
Thereafter, distal anastomosis was performed by first inserting the 5-cm graft as the elephant trunk, and the 4-branched graft was anastomosed to the transected aorta. A proximal anastomosis was performed, and the heart was restarted. The left common carotid and innominate arteries were reconstructed. Finally, the graft anastomosed to the LSCA was reconstructed (Figure 2-c). Postoperative CT showed antegrade flow to the supra-aortic vessels (Figure 2-d).