Case Presentation
A 32-year-old female with no significant prior medical history was diagnosed with angina due to a slit-like anomalous right coronary artery traversing between the aorta and pulmonary artery. She subsequently underwent right internal thoracic artery (RIMA) to right coronary artery bypass grafting at an outside facility. Her angina recurred 6 months later; repeat coronary angiography demonstrated RIMA graft occlusion and interval development of severe stenosis in the mid right coronary artery. Our multidisciplinary heart team thus recommended revascularization via redo sternotomy with saphenous vein grafting given unsuitable radial anatomy.
During the redo sternotomy and dissection of the anterior mediastinum, the RIMA graft was well-adhered to the right side of the aorta (near the superior vena cava (SVC). Likely during this dissection and exposure of the aorta for cannulation, a subadventitial aortic plane was inadvertently entered. Consequently, during aortic cannulation, a significant aortic tear without dissection developed in the distal ascending aorta, extending laterally toward the SVC beyond the site of the aortic pursestring sutures. Given how denuded the aorta was near the tear, the decision was made to maintain digital control of the large aortic tear (as best as possible) while the left femoral artery was cannulated and the patient was cooled for circulatory arrest in order to repair the tear in a bloodless field. After 45 minutes of cooling to a temperature of 22 degrees Celsius, digital control was relinquished and circulatory arrest commenced. The denuded aorta was excised back to healthy tissue, resulting in a large circular defect in the distal ascending aorta/proximal arch. A Dacron Gelweave ascending aortic tube graft with a side-arm (Terumo Aortic, Sunrise, FL) was opened. The side-arm of the graft was then cut out with a generous skirt of surrounding Dacron material to create a large patch that also served as the arterial inflow for the remainder of the operation (Figure 1 ).