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.