A 62-year-old man had a history of acute type B aortic dissection, hypertension, and dyslipidemia. Computed tomographic angiography (CTA) revealed an aberrant left subclavian artery (ALSA) originating from a right aortic arch and Kommerell's diverticulum (42 mm). Aortic dissection of the thrombotic obstruction type was observed at the descending aorta, and the dissociation cavity almost disappeared 1 year after onset. The maximum diameter of the descending aorta was 31 mm. The cervical branches originated individually from the arch in the following order: left common carotid artery (LCCA), right common carotid artery (RCCA), right subclavian artery (RSCA), and ALSA. (Fig. 1)
The ALSA was located on the dorsal side of the tracheal bifurcation, and operation of the distal anastomosis was expected to be difficult. Total arch replacement using an open stent graft with a median sternotomy was planned. After induction of general anesthesia, a midline sternotomy was performed, and the left femoral artery was exposed. The cervical branches were exposed before cardiopulmonary bypass (CPB). After heparinization, a 16 Fr cannula was inserted into the left femoral artery; a 20 Fr cannula was inserted into the ascending aorta, which was connected to the arterial line of the CPB circuit. Cannulas were inserted into the superior and inferior vena cava, connected to the venous line of the CPB circuit, and CPB was started. After starting CPB, a vent cannula was inserted through the right upper pulmonary vein, and the whole body was cooled to 27.5°C with the rectal temperature as an index. Since ventricular fibrillation was observed during cooling, the ascending aorta was clamped, and cardioplegia was administered anterogradely and retrogradely to obtain cardiac arrest. Thereafter, cardioplegia was administered antegrade and retrograde every 20 min. CPB was stopped when the target temperature was attained, and an aortotomy was performed. A cerebral perfusion catheter was placed in each cervical branch, and selective antegrade cerebral perfusion was initiated. As it was difficult to anastomose the distal arch, we assumed the distal part of the LCCA as the anastomosis line and transected the aorta at the same site. The RSCA and RCCA were transected, and their proximal sides of RSCA and RCCA were closed with 4 − 0 polypropylene continuous sutures. Each cerebral perfusion catheter was moved distally. A frozen elephant trunk (FROZENIX 35 mm × 90 mm; Japan Life Line, Tokyo, Japan) was anterogradely inserted into the aorta, and a polytetrafluroethylene (PTFE) felt (15 mm) was applied to the outside of the distal aorta. The distal side of the aorta was formed by suturing with PTFE felt, and the aorta and frozen elephant trunk continuously using 4 − 0 polypropylene. A 9-mm Dacron graft (J graft: Japan Life Line, Tokyo, Japan) was previously sutured to a 4-branch Dacron graft (J graft, 26 mm), and the 5-branch Dacron graft was anastomosed to the distal arch using 3 − 0 polypropylene. The lateral branch was connected to the arterial line of the CPB circuit, and lower body perfusion was restarted. Rewarming was started after anastomosis of the RSCA and side branch with 5 − 0 polypropylene. The aorta was transected 10 mm distal to the sinotubular junction. A PTFE felt (10 cm) was applied to the outside of the aorta, and proximal anastomosis was performed with 4 − 0 polypropylene. Terminal warm blood cardioplegia (antegrade and retrograde) was administered, the air was vented, and the cross-clamp was released. The remaining cervical and lateral branches were anastomosed using 5 − 0 polypropylene (RCCA, LSCA, and LCCA, accordingly). The proximal side of the LSCA originating from Kommerell's diverticulum was closed using a 4 − 0 polypropylene continuous suture. After rewarming, the CPB was withdrawn. The bypass times were as follows: CPB (319 min), SACP (242 min), and distal ischemic time (86 min with distal perfusion).
After surgery, the patient was admitted to the intensive care unit and extubated 9 days after surgery due to delayed alertness. He was discharged 28 days after the operation without any major complications. Follow-up CTA at 12 months postoperatively confirmed no endoleak, anastomotic stenosis, or other problems. (Fig. 2)