Clinical Summary
IRB approval, a consent statement, and clinical trial registration are
not applicable for this study. A 53-year-old male underwent coronary
artery bypass grafting with a postoperative course complicated by MRSA
mediastinitis, requiring multiple mediastinal re-explorations and an
eventual flap closure. He was readmitted 2 months later with CTA chest
demonstrating a 3.6-cm bilobed PSA with a large entry site at the
anterior proximal aortic arch (Figure 1). The location and size of the
entry as well as infectious etiology precluded an endovascular approach,
and the anterior entry surrounded by a large amount of thrombi raised
significant concern for the intraoperative migration of thrombi into the
systemic circulation during the necessary sternal reentry with
circulatory arrest.
In the operating room, left femoral artery access was obtained and
pre-closed. Cardiopulmonary bypass was initiated via the right axillary
artery and femoral vein, with a left ventricular apical vent placed
through a small left anterior thoracotomy. When the patient was reaching
the goal temperature of 20°C, a 34x100 mm Relay graft (Bolton Medical,
Sunrise, FL, USA), introduced through the left femoral artery access
site, was positioned in the aortic arch under fluoroscopic guidance.
Cardiac arrest was then achieved with systemic potassium and deep
hypothermic circulatory arrest was induced. The TEVAR graft was promptly
deployed to prevent thrombus migration from the PSA (Figure 2)(Figure
3). Occlusion of the orifices of the head vessels with the TEVAR allowed
effective antegrade cerebral perfusion via the axillary artery cannula,
confirmed by the presence of adequate right radial artery pressure and
excellent bilateral cerebral saturations via cerebral oximetry. A repeat
median sternotomy immediately followed, upon which the PSA was entered.
After thorough debridement of a massive amount of fresh thrombi, a large
defect was noted at the prior aortic cannulation site. The innominate
artery was dissected out and clamped. The TEVAR graft was explanted
through the large entry site. The PSA entry site was extended, and the
aortic lumen was carefully inspected to confirm clearance of any
potentially embolic particles. The defect was repaired with a bovine
pericardial patch, and the systemic circulation was restarted after
de-airing. The patient was weaned from bypass without incident and the
chest was closed in standard fashion. Cultures from the operating room
were positive for MRSA.
He was then taken to the ICU and was extubated within 24 hours. While no
postoperative stroke nor recurrence of mediastinitis was observed, the
patient suffered a mechanical fall after being successfully discharged
from the ICU, and he eventually expired on postoperative day #75 due to
pneumonia.