Balloon and Glue Technique: A Modification of Distal Reinforcement to Prevent Anastomotic New Entry, Reducing Replacement Range in Acute Type A Aortic Dissection

Figures

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  Fig. 1. Schematic and actual images of a distal anastomotic new entry tear in a dissection operation. (A) Challenges faced by surgeons at the distal anastomotic site in the context of acute type A aortic dissection. A distal anastomotic new entry tear (indicated by the star) can serve as an entry point into the false lumen (denoted by the arrow) to maintain its patency. This can lead to subsequent aneurysmal changes. (B) Coronal view following ascending aorta replacement. The image reveals a patent false lumen (indicated by arrowheads), in contrast to the preoperative thrombosed false lumen. (C) Sagittal view of distal anastomotic new entry tear (indicated by the star). (D) Coronal view of distal anastomotic new entry tear (denoted by the arrow). (E) Sagittal view of the same case.

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  Fig. 2. Distal end anastomosis. (A) A balloon-tip catheter was inserted into the neck vessels for selective cerebral perfusion (SCP) following circulatory arrest, while maintaining a dry field. Further details on SCP are not discussed herein. (B) The aortic balloon was carefully inserted into the true lumen and inflated just distal to the left subclavian artery. Subsequently, small pieces of gauze were placed in front of the true lumen to prevent glue from dripping. (C) BioGlue (Cryolife Inc., Kennesaw, GA, USA) was injected into the false lumen. (D) The aortic balloon was shifted 1–2 seconds following injection. (E) Subsequently, the aortic balloon was positioned to ensure adhesion of the false lumen at the transverse arch. Reinforcement at the distal site was completed after a 2-minute waiting period. (F) The graft was anastomosed using a 4-0 polypropylene suture in a standard fashion, having been stabilized by BioGlue (indicated by the star).

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  Fig. 3. Representative case of hemiarch replacement in which the distal anastomosis was reinforced using the balloon-and-glue technique. (A) Preoperative computed tomography (CT) reveals an entry tear (indicated by the arrow) at the junction of the ascending aorta and the aortic arch, seen in the axial view. (B) Preoperative CT shows an entry tear (indicated by the arrow) and a false lumen (marked with an asterisk) involving the lesser curvature of the aortic arch, seen in the coronal view. (C) CT performed on postoperative day 7 reveals the distal anastomosis (indicated by dotted arrows) in the axial view. (D) CT performed on postoperative day 7 reveals the distal anastomosis (indicated by dotted arrows) and proximal arch with a sealed false lumen (denoted by arrowheads) in the coronal view. This technique successfully eliminated the false lumen depicted in image (B).