Search

Surgery for acute aortic dissection is challenging, especially in cases of cerebral malperfusion. Should we perform only the aortic repair, or should we also reconstruct the arch vessels when they are severely affected by the disease process? Here we present a case of acute aortic dissection with multiple tears that involved the brachiocephalic artery and caused cerebral and right upper-extremity malperfusion. The patient successfully underwent complete replacement of the brachiocephalic artery and the aortic arch during deep hypothermic circulatory arrest, with antegrade cerebral protection. We have found this technique to be safe and reproducible for use in this group of patients.

A patient presented with severe triple-vessel coronary artery disease, including multiple lesions on the left anterior descending coronary artery (LAD), which supplied a well-contracting myocardium. In approaching our patient, we judged that a pedicled left internal thoracic artery (LITA) would not provide enough length for sequential grafting of the multisegment-diseased LAD. We also considered that a pedicled right internal thoracic artery (RITA) conduit would not be long enough to provide a free segment that would form a tandem graft with a LITA and then arrive at the marginal branch, unless it was detached at its origin. Consequently, we decided to form a composite graft that would connect a free, short segment (6-7 cm) of pedicled LITA to the in situ pedicled RITA, in an end-to-end fashion. This new composite conduit enabled us to perform sequential grafting (3 sequential anastomoses, 2 with the LITA segment) of the multisegment-diseased LAD, following the route anterior to the aorta. The in situ remnant of the LITA was grafted to the marginal branch. Although many large series have reported resourceful solutions, to the best of our knowledge, tandem arterial sequential grafting (an in situ pedicled RITA plus a free, short segment of a pedicled LITA) has not heretofore been reported in application to the multisegmented-diseased LAD artery. We strongly believe that this technique is an attractive variation on bilateral pedicled ITA left-sided revascularization in cases of multivessel coronary artery disease, including LADs with multiple lesions.