Staged repair for infected aortic arch graft and branched endograft post type A dissection repair.

A quinquagenarian underwent zone 2 arch repair for acute type A dissection followed by endovascular repair utilizing a branch endoprosthesis and covered stents. He developed a fever and positive blood culture results 3 weeks after the thoracic endovascular repair. A preoperative left carotid to subclavian artery bypass was performed. First stage: A right axillary artery was re-cannulated. The innominate vein was divided to facilitate the exposure. At a bladder temperature of 20℃, selective antegrade cerebral perfusion was established. A bifurcated graft was anastomosed to the left common carotid artery and the innominate artery. The endografts, including a branch endograft, were removed. A classical elephant trunk graft was inserted into the descending aorta and the left subclavian artery was ligated. The elephant trunk was pulled out and a proximal anastomosis was performed. Finally, the bifurcated graft was anastomosed to the elephant trunk. The innominate vein was repaired. Delayed closure with the pectoralis major muscle flap was performed. Second stage: A descending aortic repair was performed using a partial femoro-femoral bypass. The distal aortic arch was clamped, including the residual endograft and the elephant trunk. Covered endografts were removed. An open distal anastomosis was performed above the celiac axis utilizing a Dacron graft followed by the proximal elephant trunk-to-graft anastomosis. After completion of the repair, residual covered endografts were removed completely.