Bagozzi, Lorenzo

Bellanti, Ermanno

Bottio, Tomaso

Gerosa, Gino

Padua Research Archive

Treatment of aortic dissection involving the right coronary

BELLANTI, ERMANNO

Archivio istituzionale della ricerca - Università di Padova

Original Citation:Treatment of aortic dissection involving the right coronaryMosby Inc.Publisher:Published version:DOI:Terms of use:Open Access(Article begins on next page)This article is made available under terms and conditions applicable to Open Access Guidelines, as described athttp://www.unipd.it/download/file/fid/55401 (Italian only)Availability:This version is available at: 11577/3275361 since: 2018-08-20T12:24:40Z10.1016/j.jtcvs.2018.05.103Università degli Studi di PadovaPadua Research Archive - Institutional RepositorySURGICALTECHNIQUETreatment of aortic dissection involving the right coronaryErmanno Bellanti, MD, Lorenzo Bagozzi, MD, Gino Gerosa, MD, and Tomaso Bottio, MD, PhD, Padua,ItalyFrom the Division of Cardiac Surgery, Department of Cardiac, Thoracic and Vascular Sciences, University of Pa-dua, Padua, Italy.Drs Bellanti and Bagozzi contributed equally.Disclosures: Authors have nothing to disclose with regard to commercial support.Received for publication March 28, 2018; revisions received May 20, 2018; accepted for publication May 28,2018.Address for reprints: Tomaso Bottio, MD, PhD, Cardiac Surgery Unit, Via Giustiniani, 2, 35128, Padua, Italy(E-mail: tomaso.bottio@unipd.it or tbottio@gmail.com).J Thorac Cardiovasc Surg 2018;-:1-30022-5223/$36.00Copyright  2018 by The American Association for Thoracic Surgeryhttps://doi.org/10.1016/j.jtcvs.2018.05.103A, Coronary plasty of right coronary artery. B, Finalcomplete repair.Central MessageWe describe an aortic dissection with ostialinvolvement of anomalous right coronary ar-tery. The right coronary artery was repairedand reimplanted by interposing a pericardialpatch.See Editorial Commentary pageXXX.Video clip is available online.Aortic dissection with flap extension into coronary arteriesstill represents a surgical challenge. In this report, we reporta case of type A aortic dissection with ostial involvement ofan anomalous right coronary artery (RCA) origin and intra-mural path. After Tirone David valve-sparing aortic rootand arch replacement, the RCA was repaired and reim-planted onto the Dacron polyester fabric prosthesis by inter-posing a pericardial patch. We suggest a new approach tocoronary artery reimplantation, providing a more physio-logic anastomosis with respect to the anatomic pattern.The institutional review board has approved this article.TECHNIQUEA 60-year-old woman was referred to the emergencydepartment because of chest and left leg pain. Computedtomographic angiographic scans revealed a type A aorticdissection that extended form the aortic root to the iliac ves-sels (Figure 1, A-C).Cardiopulmonary bypass was established through theright axillary artery and the right femoral vein. An addi-tional venous drain was placed into the superior venacava. One-shot cold crystalloid HKT Custodiol cardiople-gia (Essential Pharmaceuticals LLC, Durham, NC) wasadministered into the coronary ostia, and 22C of hypother-mia was achieved. At the surgical inspection, we found thatthe dissection flap involved the RCA. Moreover, the rightcoronary ostium was above the sinotubular junction, andthe course was intramural in its proximal tract (Figure 2, A).Because the aortic valve was preserved but the aortic rootwas involved, we opted for a valve-sparing aortic root replace-ment, which was performed according to the Tirone DavidThe Journal of Thoracic and Ctype I technique. The RCAwas reconstructed in 3 subsequentsteps: (1) by shortening the proximal intramural portion withelimination of the dissected tract (Figure 2, B); (2) by rein-forcing the distal intramural tract, once isolated from the sinusaorta, suturing together theRCA’s layers with aortic wall rem-nants (Figure 2, C); and (3) by interposing a bovine pericar-dial patch to anastomose the reconstructed RCA (Figure 3,A and B). This alternative surgical technique was intendedto create new, pliable coronary ostium, to avoid vessel distor-tion, and to facilitate the execution of anastomosis. With thepatient receiving selective anterograde cerebral perfusion,the aortic arch was examined. The flap dissection involvedthe first 2 supra-aortic vessels. The aortic arch was replacedwith a Dacron polyester fabric prosthesis with 2-plus-1 sidebranches. The left subclavian artery was not involved by thedissection and originated from the true lumen; for these rea-sons, it was not reimplanted. Cerebral monitoring was per-formed by continuous measurement of cerebral oxygensaturation (INVOSTM; Medtronic Inc, Minneapolis, Minn).Surgical times were as follows: ischemic time of 220minutes,cardiopulmonary bypass time of 350 minutes, and selectivecerebral perfusion time of 60minutes. Transesophageal echo-cardiography revealed a normal biventricular functionwithout hypokinesia areas and the perfect competence ofthe aortic valve.The patient’s extubation was possible within a few hoursafter surgery, and the zenith troponin level was 30.526 ng/L.No surgery-related or neurologic complications occurred,ardiovascular Surgery c Volume-, Number- 1FIGURE 1. Preoperative computed tomographic scans. A, Involvement of the aortic root at the level of the coronary ostium. B, Involvement of the epiaorticvessels’ origins. C, Three-dimensional reconstruction of aortic dissection.Surgical Techniqueintensive care unit stay was 3 days, and the patient wasreferred to the rehabilitative center on the 6th postoperativeday. At 6-month follow-up, the patient was leading a normallife, and check-up assessments revealed good surgicalresults.DISCUSSIONThe treatment of coronary dissection represents a surgi-cal challenge and increases the risk of mortality andmorbidity for aortic dissection by as much as 6.1% to11.3%.1,2Several classifications of coronary involvement in aorticdissection have been proposed. Neri and colleagues3 distin-guish 3 main types of lesions according to the extension ofthe dissection flap within the coronary artery. They describea range of situations, from the isolated ostial dissection tothe circumferential detachment with inner intussusception.3Unfortunately, the coronary lesion presented in our reportdoes not match the classification of Neri and colleagues,3given the intramural vessel course and the anomalousorigin.FIGURE 2. A, Surgical view of type A aortic dissection with the intramural ricourse. C, Isolation of the right proximal coronary artery tract.2 The Journal of Thoracic and Cardiovascular SurgerDespite concerns regarding graft obstruction, one of theindications for the Cabrol technique remains aortic dissec-tion with coronary involvement. In fact, the Cabrol proced-ure provides a tension-free anastomosis of the coronaryarteries to the aortic conduit in the presence of malacicvascular tissue and a limited chance of mobilization of thevessels.4Another surgical solution is the coronary ostial ligatureand coronary artery bypass grafting. This should be consid-ered a rescue procedure for the competitive flow and coro-nary re-dissection risk with the complete graft-dependentperfusion of large myocardium myocardial territories.3Because of the dubious results of the Cabrol procedureand coronary artery bypass grafting in this specific disease,a coronary repair technique has recently been described thatuses patch interposition with either saphenous vein orbovine or equine pericardium.Westaby and associates5 sug-gest the use of a semicircular hood pericardial patch toavoid coronary tension, but only in elective surgery.With respect to our urgent case, wewere faced with 2 sur-gical challenges: first, the involvement in the dissection ofght coronary artery pattern. B, Anomalous intramural right coronary arteryy c- 2018FIGURE 3. A, Coronary plasty of right coronary artery. B, Final complete repair.Surgical Techniquethe RCA; and second, the RCA’s anomalous origin andcourse. We demonstrate here an alternative 3-step surgicaltechnique to reconstruct and reimplant the RCA onto theneoaortic root by interposing a bovine pericardial patch.This procedure provides an anatomic reimplantation ofVIDEO 1. Commentary of one of the authors (T.B.) discussing the rele-vance of the article. Video available at: http://www.jtcvs.org.The Journal of Thoracic and Cthe coronary vessel, even in the case of anomalous originand intramural course. Furthermore, unlike the Cabrol tech-nique, it preserves the physiologic pattern of coronary flow.Finally, the anastomosis between 2 biologic surfaces(bovine pericardium and coronary artery) reduces the riskof surgical bleeding, which is especially useful in emer-gency surgery (Video 1).References1. Waterford SD, Di Eusanio M, Ehrlich MP, Reece TB, Desai ND, Sundt TM, et al.Postoperative myocardial infarction in acute type A aortic dissection: a reportfrom the International Registry of Acute Aortic Dissection. J Thorac CardiovascSurg. 2017;153:521-7.2. Geirsson A, Szeto WY, Pochettino A, McGarvey ML, Keane MG, Woo YJ, et al.Significance of malperfusion syndromes prior to contemporary surgical repair foracute type A dissection: outcomes and need for additional revascularizations. EurJ Cardiothorac Surg. 2007;32:255-62.3. Neri E, Toscano T, Papalia U, Frati G, Massetti M, Capannini G, et al. Proximalaortic dissection with coronary malperfusion: presentation, management, andoutcome. J Thorac Cardiovasc Surg. 2001;121:552-60.4. Kourliouros A, Soni M, Rasoli S, Grapsa J, Nihoyannopoulos P, O’Regan D, et al.Evolution and current applications of the Cabrol procedure and its modifications.Ann Thorac Surg. 2011;91:1636-41.5. Westaby S, Katsumata T, Vaccari G. Coronary reimplantation in aortic rootreplacement: a method to avoid tension. Ann Thorac Surg. 1999;67:1176-7.ardiovascular Surgery c Volume-, Number- 3Surgical Technique000 Treatment of aortic dissection involving the right coronaryErmanno Bellanti, MD, Lorenzo Bagozzi, MD, Gino Gerosa, MD, and Tomaso Bottio, MD, PhD,Padua, ItalyWe describe an aortic dissection with ostial involvement of anomalous right coronary artery. Theright coronary artery was repaired and reimplanted by interposing a pericardial patch.The Journal of Thoracic and Cardiovascular Surgery c- 2018

Archivio istituzionale della ricerca - Università di Bari

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Treatment of aortic dissection involving the right coronary

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