PMC6290257_01
Preoperative computed tomography images.. (A) Saccular type aortic arch aneurysm (solid arrow) and aberrant right subclavian artery (white arrow). (B) Shaggy aorta was acknowledged (white arrow). (C) Aortic stenosis at the level of the thoracoabdominal aorta and infra-renal abdominal aorta (gold arrows). Right renal artery had severe stenosis (white arrow). (D, E) Abdominal aorta was 19 mm just above celiac artery (CA), it become more stenosis at renal level (13 mm).
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Contrast-enhanced computerized tomography (CT) revealed a saccular aortic aneurysm with a diameter of 68 mm on the middle aortic arch (Fig. 1A) without any relevant complications. Severe diffuse aortic stenosis (Fig. 1C, D, E) was confirmed in the thoracoabdominal and infra-renal abdominal aortae with severe calcification and shaggy aorta (Fig. 1B). The orifice of the bilateral renal arteries was also stenosed and calcified (Fig. 1C). Chest X-ray showed enlargement of aortic arch (Fig. 1G).
Postoperative three-dimensional computed tomography findings.. Graft of total arch replacement (a) at the area from the sinotubular junction (unfilled arrow) to the distal aortic arch (filled arrow). Extra-anatomical bypass is established to the right axillary artery (b) and graft from total arch replacement to the femoro-femoral crossover bypass graft (c). LAx, left axillary artery; LCCA, left common carotid artery; RAx, right axillary artery; RCCA, right common carotid artery.
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Under deep hypothermic circulatory arrest at a bladder temperature of 25  C, the aortic arch was transected at the distal portion of the orifice of the aberrant right subclavian artery (Fig. 2A, B). During systemic rewarming, inflow anastomoses of extra-anatomic bypass graft from the ascending aortic graft to the femoro-femoral crossover bypass graft was established to maintain circulation blood perfusion to the lower body for MAS (Fig. 2C).
Intro-operative picture. A: aorta. B: aberrant right subclavian artery. C: Total image of total procedure finished.
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Three-dimensional CT showed that all grafts were patent without stenosis (Fig. 3).
Computed tomography findings showed that graft was patency (white arrow).
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There was no any complications induced by graft stenosis or occlusion two years postoperative, the bypass graft to femoral arteries is patency (Fig. 4).