Treatment strategies for left subclavian artery during total arch replacement combined with stented elephant trunk implantation

ObjectiveOne of the technical challenges in total arch replacement for type A aortic dissection is the left subclavian anastomosis and the descending aortic anastomosis. We present a technique that simplifies this surgery.MethodsA total of 33 consecutive patients (mean age, 48.0 ± 11.6 years) with acute Stanford type A aortic dissection who underwent a total arch replacement were included in this study. Instead of anastomosing the graft to the descending aorta distal to the left subclavian artery, we ligated the left subclavian artery and performed the distal aortic anastomosis between the left carotid artery and the left subclavian artery. The left subclavian artery is then revascularized with a side arm from our aortic graft through the first intercostal space to the left axillary artery. The descending aorta also is stented in an antegrade fashion under direct visualization. Both intraoperative and postoperative complications were then noted.ResultsAll enrolled patients underwent total arch replacement performed using this newly introduced technique with a mortality rate of 18.2% (6/33). The causes of mortality were multiorgan failure (4 patients), renal failure (1 patient), and postoperative sepsis (1 patient). There was no intraoperative death and no anastomotic leak in our study cohort. Limb ischemia was observed in 4 patients, with all occurring in the lower limb. Postoperative delirium also was observed in 5 patients.ConclusionsThe left subclavian artery bypass technique during total arch replacement for type A dissection is reliable and simplifies the surgery by bringing the descending aortic anastomosis more proximal and eliminating the difficult left subclavian artery anastomosis.