1. LEFT SUBCLAVIAN ARTERY REVASCULARIZATION DURING DEBRANCHING PROCEDURE FOR ACUTE “TYPE A“ AORTIC DISSECTION USING THE LEFT INTERNAL MAMMARY ARTERY
Thank you this opportunity, im paolo magagna, I work in Vicenza Italy, I start my presentation
Paolo Magagna, MD
Dept CardioVascular Surgery San Bortolo Hospital, Vicenza, Italy
Chief: Loris Salvador, MD

2. I have no financial relationships to disclose

3. Background
The management of the left subclavian artery (LSA) during a Frozen Elephant Trunk (FET) with debranching of the supra-aortic vessels is controversial and sometimes challenging, especially during an emergency life-saving procedure, such as a type A acute aortic dissection.
Although there are many potential complications following subclavian artery occlusion (including stroke, spinal cord ischemia or upper limb ischemia), if LSA coverage is necessary during FET, it is still debated whether it should be revascularized or not

4. Even if recent guidelines issued by the SVS suggest LSA revascularization whenever possible, evidence based data supporting these recommendations are still missing

5. “Gold standard” for the LSA revascularization
Direct revascularization (end-to-end anastomosis)
Carotid-subclavian artery bypass
Aorto-subclavian/axillary bypass
Drawbacks
Complications:
vocal cord paralysis, phrenic nerve palsy, vagus nerve injury, brachial plexus injury, bleeding, thoracic duct injury, lymphocele, and sympathetic nerve injury resulting in Horner’s syndrome
Unfavorable anatomy, calcifications, anomalous origin, etc.
Technically demanding especially for inexperienced surgeons and during emergency surgery

6. Aim of this presentation
We hereby describe a novel technique to revascularize the LSA during FET with aortic arch debranching
LIMA harvesting (as a conventional CABG)
LIMA distal anastomosis to the ascending aorta/vascular prosthesis with consequent blood
“Backflow” LIMA to LSA
Closure of the LSA (direct/plug)

7. CASE PRESENTATION
A 64-year-old man, with a history of hypertension and smoking, was admitted to the I.C.U. for Type A Acute Aortic Dissection and underwent emergency surgery

8. Surgical technique (1) Median sternotomy
Right axillary artery cannulation
Moderate hypothermia 26°C
Brain protection with selective antegrade cerebral perfusion
Aortic Valve Replacement with Stentless Edwards Prima Plus 25 mm
Ascending aorta and aortic arch replacement with debranching of the Innominate artery and left common carotid artery (Lupiae™ Branched Arch Graft 30/10/10/8)
Frozen Elephant Trunk (E-vita open plus) with coverage of the LSA
Unfavorable anatomy for LSA revascularization

9. Surgical technique (2) Rewarming LIMA Harvesting
In-situ LIMA to ascending aorta vascular prosthesis anastomosis (prolene 7/0)
Closure of the origin of the left subclavian artery with direct suture
During rewarming

10. Operative data CPB time: 314’ Aortic Cross Clamp time: 122’
Circulatory arrest time: 33’
Cerebral perfusion time: 53’
Ultrasound Doppler Flow measurement on the LIMA:
150 ml/min
The postoperative course was uneventful and the patient was discharged from the ICU on the fifth postoperative day and from the hospital on the tenth postoperative day
Δ arterial pressure left arm vs right arm: 20 mmHg

11. Follow up

12. ANGIO CT-SCAN 12 MONTHS AFTER THE OPERATION
POSTERIOR VIEW
ANTERIOR VIEW

13. VASCULAR ECHO-COLOR DOPPLER
Right SA
Left SA
Good flow but slightly lower flow velocity in the left SA vs. right SA

14. TRANS-CRANIAL DOPPLER
Evidence of antegrade flow in left vertebral artery

15. Conclusions
LSA revascularization with LIMA to ascending aorta anastomosis in order to achieve blood “backflow” during FET with arch debranching is technically feasible
At 12 months follow up Angio-CT scan, vascular echo-Doppler and TCD show good patency of the bypass with excellent flow in the LSA and antegrade flow in the left vertebral artery
This technique seems easy and reproducible even if further data are needed to assess its safety and efficacy

16. debranching@gmail.com paolo.magagna@libero.it
This is the patient who clearly shows good strength in his left arm, winning arm wrestling