Staged Repair for Infected Aortic Arch Graft and Branched Endograft in a Patient with a History of Open Zone 2 Arch Repair and Sequential TEVAR for Complex Acute Type A Aortic Dissection

S. Ohira, D. Spielvogel
Westchester Medical Center, Valhalla, New York

Please explain the educational or technical point that this video addresses.: With the evolution of technology, thoracic endovascular repair (TEVAR) has been implicated in complex aortic pathologies.
In this case, a quinquagenarian with a history of open Zone 2 aortic arch repair for acute type A aortic dissection followed by endovascular repair (TEVAR) utilizing a branched endoprsothesis to compete aortic arch and descending thoracic aorta repair. He developed fever and positive blood culture (Staph. Epidermidis) which was found to be graft infection in surgical arch graft as well as endograft. Staged repair (Stage 1 reoperative aortic arch repair with insertion of classical elephant trunk, and Stage 2 thoracoabdominal aortic repair) was performed successfully.
Staged-repair was perfromed given exposure of neck vessels, prior histories of extensive aortc repair and invasivness of one-stage repair (Clamshell Incision, anterolateral thoracotomy with partial sternotomy, etc) which may carry risks of longer pump time, respiratory failure, renal failure and so on. This video highlights strategy and techniques of complex repair of surgical graft and endograft infection.

Please provide a 250 word summary of the surgical video being submitted.: Prior to 1st stage repair, left carotid –subclavian (LSCA) bypass was performed.
First stage: Redo right axillary artery cannulation was performed. After sternal re-entry, the innominate vein was divided. At a bladder temperature of 20℃, the innominate artery and left common carotid artery were clamped to establish unilateral antegrade cerebral perfusion (ACP). A bifurcated graft was anastomosed to the left common carotid artery and innominate artery, respectively, which established bilateral ACP. The aortic arch was resected. Multiple endografts included a branched endograft were removed. A 26 mm graft was inserted to the descending thoracic arota as an elephant trunk and the LSCA was ligated. The inverted graft was retrieved and anastomosed at the sinotubular junction. The proximal part of the bifurcated graft was anastomosed to the ascending graft, and systemic perfusion with rewarming was resumed. The innominate vein was sewn back together. As the omentum was not available, the patient underwent muscle flap around the graft utilizing the pectoralis major muscle in the following day.
Second stage repair: Sixth intercostal space was entered and intercostal arteries were sacrificed prior to partial femoro-femoral bypass. Distal aortic arch was clamped including residual endograft and elephant trunk. Covered endografts were incised and removed. Open distal anastomosis was performed above the celiac axis utilizing a 26 mm Dacron graft followed by restoration of blood flow to the lower body. Proximal graft-to-elephant graft anastomosis was performed. After completion of aortic repair, residual covered endograft was removed completely. Native aortic tissue was wrapped around Dacron graft.