Type A Aortic Dissection After Extra-Anatomic Coarctation Repair

Figures

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  Visual Summary. Summary of the Case Report Summary of the medical history, detection of an ATAAD, and surgical reconstruction. Ao = aorta; ATAAD = acute type A aortic dissection; CT = computed tomography; MRI = magnetic resonance imaging; POD = postoperative day.

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  Figure 1. Cardiac Magnetic Resonance Imaging Before Coarctation Repair Magnetic resonance angiography (A and B) with 3-dimensional reconstructions demonstrating tortuous aorta with coarctation (C and D).

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  Figure 2. Serial Imaging Follow-Up After Extra-Anatomic Ascending-to-Descending Aortic Bypass Multiplanar computed tomography images showing the proximal (A) and distal (B) portions of the bypass graft as well as the Desc Ao (C). A pseudodiverticulum is visible along the inferior surface of the graft (A). Three-dimensional reconstruction illustrates the overall aortic anatomy (D). Cardiac magnetic resonance 4-dimensional flow imaging confirms graft patency (E and F). Ao = aorta; Asc Ao = ascending aorta; Desc Ao = descending aorta; IVC = inferior vena cava; RA = right atrium; RCA = right coronary artery.

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  Figure 3. Serial Echocardiography Demonstrating Progressive Aortic Root and Ascending Aorta Dilation Progressive dilation of the aortic root (blue) and ascending aorta (red) over 13 years after extra-anatomic coarctation bypass. Abbreviation as in Figure 1.

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  Figure 4. Incidental Acute Type A Aortic Dissection Identified on Routine Serial CMR Surveillance Multiplanar CMR images showing the ascending aortic dissection in the axial plane (A) and the enlarged dissected aortic root with the bypass graft adjacent (B). The distal bypass appears unaffected (C). Three-dimensional reconstruction illustrates the spatial relationships of the aorta and graft (D), with the dissection highlighted by a yellow arrow. Magnetic resonance angiography depicts the thoracic aorta (E), and 4-dimensional flow imaging confirms patency of the bypass graft with maintained flow to the distal aorta and branch vessels (F). CMR = cardiac magnetic resonance; other abbreviations as in Figure 1.

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  Figure 5. Preoperative CT Angiography Confirming the Acute Type A Aortic Dissection Multiplanar CT axial views showing the aortic arch (A), ascending aorta (B), and aortic root (C) with an acute type A dissection. The sagittal view demonstrates the false lumen located posterior to the true lumen (D). Three-dimensional reconstruction of the aorta (E). Coronary ostia appear uninvolved by the dissection (F). Yellow arrow indicates dissection. CT = computed tomography; LCA = left coronary artery; other abbreviations as in Figure 1.

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  Figure 6. Operative Sequence of Aortic Root and Arch Reconstruction With Preservation of the Extra-Anatomic Ascending-to-Descending Bypass Graft Intraoperative images showing redo median sternotomy (yellow asterisk) with dilated ascending aorta (A), sequential brachiocephalic debranching using a trifurcate Y-arch graft under bilateral ACP (B), distal anastomosis (C), proximal mechanical root replacement with coronary buttons and bypass graft reimplantation (D), and final reconstruction (E). ACP = antegrade cerebral perfusion; LV = left ventricle.

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  Figure 7. Postoperative Imaging Demonstrating Successful Aortic Repair Chest radiography showing unremarkable findings (A). Completion computed tomography angiography demonstrates a well-positioned valved conduit and arch grafts with a patent extra-anatomic bypass graft on multiplanar (B-F) and 3-dimensional (G) reconstructions. Abbreviations as in Figure 1.