Giant ascending and arch aortic aneurysms measuring up to 117 mm pose life-threatening risks of rupture and compression, making surgical management exceptionally challenging during redo cardiac procedures due to prior sternotomy and mediastinal adhesions, according to clinical case documentation. A 63-year-old male patient with a history of rheumatic heart disease and a double mechanical valve replacement underwent a successful staged re-entry strategy utilizing pre-sternotomy left ventricular apical decompression, controlled systemic cooling, and total aortic root and arch replacement, as reported in surgical case findings.
Staged Operative Strategy for Giant Sternal-Adherent Aneurysms
Safe re-entry during redo cardiac surgery requires careful preoperative planning to prevent catastrophic injury from sternal adhesions. According to the case report, clinicians established femoro-femoral cardiopulmonary bypass before resternotomy using a 19-Fr arterial cannula in the right common femoral artery and a 25-Fr two-stage venous cannula in the right common femoral vein with vacuum-assisted drainage. This peripheral cannulation allowed controlled systemic cooling and hemodynamic stability prior to median resternotomy and aneurysm dissection.
Contrast-enhanced computed tomography revealed a giant ascending aortic aneurysm measuring 117 × 116 mm that caused marked tracheal and esophageal deviation and compression. Transthoracic echocardiography confirmed severe tricuspid regurgitation resulting from extrinsic compression, while the patient’s 23-mm aortic and 29-mm mitral St. Jude Medical mechanical prostheses functioned normally.
Pro Tip: Establishing peripheral cardiopulmonary bypass before resternotomy in patients with sternal-adherent aneurysms minimizes the risk of sudden hemorrhage during chest re-entry, providing a controlled environment for complex dissections.
Left Ventricular Apical Decompression and Temperature Management
Ventricular fibrillation frequently occurs during systemic cooling and can lead to dangerous left ventricular distension and retrograde pulmonary edema if ventricular unloading is absent. To mitigate this risk, surgeons inserted a left ventricular apical vent through a left anterolateral thoracotomy to achieve early cardiac decompression, according to the procedural details.
Systemic cooling was targeted to 22°C using an alpha-stat blood gas management strategy. At this temperature, circulatory arrest with selective antegrade cerebral perfusion was administered through the brachiocephalic trunk and left common carotid artery. Total cardiopulmonary bypass time reached 439 minutes, with an aortic cross-clamp time of 110 minutes and a circulatory arrest time of 72 minutes.
Did You Know? Deep hypothermic circulatory arrest combined with selective antegrade cerebral perfusion helps protect vital organ function during complex aortic arch reconstructions requiring extended periods of circulatory standstill.
Graft Reconstruction and Postoperative Recovery
Aortic root and total arch replacement utilized a 24-mm four-branch Gelweave Plexus graft, with distal anastomoses reinforced using Teflon felt and sealed with BioGlue, as documented in the surgical report. Proximal reconstruction followed with the reimplantation of both coronary buttons, after which the aortic cross-clamp was released to allow myocardial reperfusion. Supra-arterial trunks were then sequentially reimplanted, beginning with the left common carotid artery followed by the brachiocephalic trunk.
The early postoperative course included mediastinal bleeding requiring surgical re-exploration, severe acute respiratory distress syndrome, stage 3 acute kidney injury, and cholestatic liver dysfunction. According to the medical team, multidisciplinary critical care management successfully resolved these complications. Postoperative computed tomography and echocardiography confirmed preserved biventricular function and stable peri-prosthetic fluid collections measuring approximately 61 to 65 mm without signs of infection or contrast extravasation, allowing the patient to be discharged in stable condition after six weeks.
Frequently Asked Questions
What are the primary surgical risks of redo aortic arch replacement?
Redo aortic procedures carry elevated risks of catastrophic hemorrhage, cardiac injury, and myocardial ischemia due to prior sternotomies, altered anatomy, and extensive mediastinal adhesions.
Why is pre-sternotomy left ventricular venting used?
Pre-sternotomy left ventricular venting prevents dangerous ventricular distension and pulmonary edema that can occur when ventricular fibrillation develops during controlled systemic cooling prior to chest opening.
How is cerebral protection managed during total arch replacement?
Clinicians typically combine deep or moderate hypothermia with selective antegrade cerebral perfusion delivered through the brachiocephalic and left common carotid arteries during periods of circulatory arrest.
What complications are common after complex aortic arch surgery?
Reported postoperative complications include mediastinal bleeding requiring re-exploration, respiratory failure, acute kidney injury, and transient multiorgan dysfunction related to prolonged cardiopulmonary bypass times.
Have you or a loved one navigated complex cardiovascular surgery? Share your experiences or questions in the comments below, and subscribe to our newsletter for the latest clinical case reports and surgical updates.