Case Presentation
A 32-year-old female with no significant prior medical history was
diagnosed with angina due to a slit-like anomalous right coronary artery
traversing between the aorta and pulmonary artery. She subsequently
underwent right internal thoracic artery (RIMA) to right coronary artery
bypass grafting at an outside facility. Her angina recurred 6 months
later; repeat coronary angiography demonstrated RIMA graft occlusion and
interval development of severe stenosis in the mid right coronary
artery. Our multidisciplinary heart team thus recommended
revascularization via redo sternotomy with saphenous vein grafting given
unsuitable radial anatomy.
During the redo sternotomy and dissection of the anterior mediastinum,
the RIMA graft was well-adhered to the right side of the aorta (near the
superior vena cava (SVC). Likely during this dissection and exposure of
the aorta for cannulation, a subadventitial aortic plane was
inadvertently entered. Consequently, during aortic cannulation, a
significant aortic tear without dissection developed in the distal
ascending aorta, extending laterally toward the SVC beyond the site of
the aortic pursestring sutures. Given how denuded the aorta was near the
tear, the decision was made to maintain digital control of the large
aortic tear (as best as possible) while the left femoral artery was
cannulated and the patient was cooled for circulatory arrest in order to
repair the tear in a bloodless field. After 45 minutes of cooling to a
temperature of 22 degrees Celsius, digital control was relinquished and
circulatory arrest commenced. The denuded aorta was excised back to
healthy tissue, resulting in a large circular defect in the distal
ascending aorta/proximal arch. A Dacron Gelweave ascending aortic tube
graft with a side-arm (Terumo Aortic, Sunrise, FL) was opened. The
side-arm of the graft was then cut out with a generous skirt of
surrounding Dacron material to create a large patch that also served as
the arterial inflow for the remainder of the operation (Figure
1 ).