Hybrid Strategy on Aortic Arch Disease

Abstract

Acute aortic syndrome (AAS) is an emergency condition that includes acute aortic dissection, intramural hematoma, aortic ulcer, and iatrogenic and traumatic aortic dissection. Initial management includes pain control (with powerful analgesics if necessary), heart rate and inotropic control with the use of beta-blockers, and strictly blood pressure control. The Stanford classification takes into account the extent of dissection to the ascending aorta, which might be present (Stanford A) or not (Stanford B). Current guidelines recommend surgical treatment for all patients with type A ASS. We report a case of a 77-year-old female who was admitted to the emergency department presenting chest pain for 15 days. Acute coronary syndrome was initially ruled out, and during diagnostic work-up, computed tomography showed an aortic arch aneurysm and important tortuosity of descending aorta. During surgery, an ascending aortic bypass was performed with a bifurcated graft anastomosis to the innominate artery and left carotid artery. The ascending aorta was partially clamped, and the proximal end-to-lateral aortic graft anastomosis was performed, followed by an end-to-lateral anastomosis of the bifurcated grafts to the innominate artery and the left main carotid artery. Twenty days after the surgery, endovascular stent implantation beginning at the ascending aorta until the descending thoracic aorta was performed. The postoperative period was uneventful, and the patient was discharged. It is known that surgical mortality of patients with aortic dissection is very high, with studies reporting rates of up to 30%. The chimney technique in arch aneurysms remains untested and should not be used as an acceptable treatment other than for salvage. There are branched prostheses for the aortic arch in the development and going through tests, and although the results are still not satisfactory, it is possible that this technique overcomes the chimney technique.