Successful repair of saccular aneurysm and dissection of descending Thoracic Aorta. [A Lilavati Hospital First]

(Dr. Pavan Kumar, Dr Shirish Borkar, Dr. Amit Modi, Dr. Asmita Hegde, Dr. Namrata Kothari)

Department Of Cardiac Surgery.

A 60 year old male patient, a case of chronic aneurysm and type B Debakey
Dissection of Aorta, with symptoms of breathlessness on exertion was
admitted to Lilavati hospital on 17/jan/2004

CLINICAL FEATURES:

CLINICALLY the patient was well built, hypertensive on antihypertensive drugs like diuretics & calcium channel blockers.  

INVESTIGATIONS :

Chest X-Ray : Aneurysm involving arch of aorta compressing one upper lobe of R lung & grossly dilated descending aorta. Coronary angiography revealed (N) coronaries with (N) L.V. Ejection Fraction.

CT Scan : 15cm x 12cm aneurysm distal to Left subclavian artery with dissection of descending aorta extending upto Bilateral common Iliac arteries involving the superior mesenteric & ® renal artery. Pt was found to have positively reacting results to TPHA & VDRL   Pt was treated with IV. Benzylpenicillin for 2 weeks and then taken up for surgery  

OT. Notes : Left anterolateral thoracotomy in Vth ICS. Left femoral vessels exposed. Left thorax entered, Dense pleural adhesions with badly stuck lung to huge aneurysm occupying the 2 / 3 of left thorax. As it was difficult to gain access proximally on arch of aorta patient put on full cardiopulmonary bypass through separate mid sternotomy and separate aortic and R.A. Cannulation. Pleural adhesions separated, Left lung gradually separated from aneurismal sac. Aneurysm sac found to be of saccular 12 cm. x 20 cm. starting from origin of left subclavian artery.   Patient put under deep hypothermia and circulatory arrest with retrograde brain perfusion. Aneurysm sac incised in length on aorta. Big false lumen dissection starting below left subclavian artery was observed.   26mm. vascutek [ collagen impregnated ] Dacron graft sutured proximally to true lumen just below left subclavian artery origin using continuous 3.0 prolene to mid thoracic aorta. Distal anastomosis obliterated false channel. Aneurismal sac excised, Bio glue applied on both anastomosis. Aneurismal sac wrapped around graft loosely. Deairing done by femoral flow. patient gradually rewarmed. CPB terminated. Hemostasis done . Heparin reversed. Decannulation done . Thoracotomy drained by two drainage tubes. Thoracotomy closed wound closed in three layers. Sternotomy closed and patient transferred to SICU in stable hemodynamic condition.

Coronary angiography done by Dr P Sanzgiri showed totally occluded LAD with no distal formation, 100% blocked Circumflex and the saphenous vein graft to OM showed 99% stenosis at distal Anastomosis. The OM was of good quality and caliber. LV angiography showed a VSD jet in the Apical region. LVEF was 30 – 35 %.

POST OF REVIEW :

Pt followed up with us in our OPD, a month later. He had resumed regular routine and was clinically fine with almost no complaints. A review CT scan was done at the same time, which revealed a well functioning prosthetic graft without leak, fully expanded (L) lung and no false lumen distally

CONCLUSION

This complex operation can be performed successfully only in a multispeciality hospital with the use of Latest technology, proper understanding of pathology and a good determined teamwork.