title: Technique for branched thoracic stent-graft repair of a chronic type a aortic dissection in a patient with multiple prior sternotomies.
abstract: OBJECTIVE
  To present a technique for endovascular treatment of a type A aortic dissection in a patient with multiple prior sternotomies and multiple medical comorbidities.
  
  
  METHODS
  The method is illustrated in a 76-year-old man with a history of hypertension, hyperlipidemia, coronary artery disease, and open repair of a type A aortic dissection via a median sternotomy. The latter procedure was complicated by a pericardial effusion requiring drainage and sternal re-wiring. The diameter of the residual type A dissection beginning just distal to the aortic root had increased by 1.5 cm over 1 year, indicating the need for further intervention. To avoid redo sternotomy, a hybrid endovascular approach was planned, but it would require landing the stent in the ascending aortic arch, thus mandating branch vessel revascularization. Prior to stent-graft deployment, right-to-left carotid-carotid and left carotid-subclavian artery bypasses were performed with 8-mm polytetrafluoroethylene grafts. Three Talent grafts were deployed from the celiac artery to the left subclavian artery. A pre-wired homemade branched Talent stent-graft (34×34×115 mm) was used to revascularize the innominate artery and secure the arch. Transvenous ventricular pacing was used to improve deployment accuracy. A 10×38-mm iCast stent was placed through the branch and extended into the innominate artery. The subclavian artery was occluded with 2 Amplatzer plugs. Postoperative computed tomography demonstrated excellent proximal fixation, a widely patent branched graft to the innominate artery, and thrombosis of the aneurysmal false lumen.
  
  
  CONCLUSIONS
  Treatment of type A dissections remains a difficult surgical challenge. The approach taken should be tailored for each patient. We successfully employed a combination of available minimally invasive techniques to treat a patient who was not ideally suited to any of the individual strategies.
authors.affiliation: Division of Vascular and Endovascular Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
authors.forename: Erin H
authors.initials: EH
authors.lastname: Murphy
authors.forename: J Michael
authors.initials: JM
authors.lastname: Dimaio
authors.forename: Michael E
authors.initials: ME
authors.lastname: Jessen
authors.forename: Frank R
authors.initials: FR
authors.lastname: Arko
mesh_terms: D000368:Aged; D000784:Aortic Dissection / Q000000981:diagnostic imaging / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000000981:diagnostic imaging / Q000601:surgery*; D001027:Aortography / Q000379:methods; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000295:instrumentation; D002304:Cardiac Pacing, Artificial; D004621:Embolization, Therapeutic / Q000295:instrumentation; D057510:Endovascular Procedures / Q000295:instrumentation; D006801:Humans; D008297:Male; D011474:Prosthesis Design; D012086:Reoperation; D015607:Stents; D056346:Sternotomy; D013348:Subclavian Artery; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome