Aortic arch pathology in a high-risk patient in whom the resternotomy approach is
unfeasible due to treated mediastinitis after ascending aortic replacement presents
a unique challenge for hybrid arch repair (HAR) because of the need for supra-aortic
debranching from unusual inflow sites other than the ascending aorta. This report
describes a “reversed sequence” extra-anatomical supra-aortic debranching procedure
as a salvage technique performed to enable HAR. An 83-year-old woman with a history
of ascending aortic replacement for type A aortic dissection, mediastinitis complicated
by sternal osteomyelitis, and a chest wall reconstructed with a rectus abdominis myocutaneous
flap presented with chest pain because of a contained dissecting arch aneurysm rupture.
The patient underwent supra-aortic debranching from the bilateral common femoral arteries
and thoracic endovascular aortic repair to the ascending aorta under cerebral near-infrared
spectroscopy (NIRS) monitoring. Completion imaging by angiography demonstrated successful
exclusion of the ruptured aneurysm. The regional cerebral oxygen saturation level,
monitored by NIRS, did not change markedly during surgery. The patient was neurologically
intact with adequate cerebral blood flow assessed postoperatively by 123I-IMP single photon emission computed tomography. Total debranching of the supra-aortic
vessels from the common femoral artery for inflow is feasible and provides adequate
cerebral perfusion. This procedure may offer an alternative treatment option in patients
with complex conditions involving aortic arch pathology.
Keywords
ruptured arch aneurysm - high-risk patient - hybrid arch repair - thoracic endovascular
aortic repair - supra-aortic debranching - cerebral blood flow - cerebral near-infrared
spectroscopy
