2025 FSA Podium and Poster Abstracts

Introduction: Aortic dissection is a life-threatening condition characterized by a tear in the inner layer of the aortic wall, leading to blood entering between the intimal and medial layers. Acute aortic dissections, presenting with severe chest pain, have high mortality without timely intervention, while chronic dissections (>2 weeks) are subtler with a better prognosis. This report details the case of a patient who developed an unusual complication involving embedded sternal wires following multiple reoperations for aortic dissection, presenting with stroke-like symptoms.

Case Description: A 67-year-old female with a history of prior type A aortic dissection treated with hemiarch replacement and mechanical aortic valve replacement presented with a residual ascending aortic dissection extending to the left common iliac artery. This patient, with no follow-up, experienced a cerebrovascular accident three years post-surgery due to inadequate anticoagulation. She underwent a staged procedure: first, a left carotid-to-subclavian bypass, followed by a re-do sternotomy with a modified Bentall procedure and thoracic endovascular aortic repair (TEVAR). The aortic graft was adherent to the sternal wires and posterior sternum, complicating dissection and necessitating hypothermic circulatory arrest before further progression. Cardiopulmonary bypass was initiated peripherally via right axillary and femoral cannulation, and the patient was re-warmed after the hemiarch replacement. Postoperatively, massive transfusion was required due to significant blood loss, leading to pulmonary edema and urgent reintubation on postoperative day 2. Despite these complications, the patient was extubated within twelve hours after reintubation and ultimately recovered without further major issues.

Discussion: This case demonstrates the complexities of reoperative sternotomy in a 67-year-old female with prior aortic surgery and mechanical valve replacement, presenting with chronic ascending aortic dissection. The surgical team opted for hypothermic circulatory arrest before completing dissection due to graft adherence to sternal wires, minimizing rupture risk. A Thoraflex Hybrid device with the Frozen Elephant Trunk (FET) technique allowed for a hybrid approach addressing the dissection and aneurysmal degeneration, reducing future intervention needs. However, extensive dissection and circulatory arrest led to intraoperative challenges, necessitating massive transfusion, which ultimately resulted in pulmonary edema and reintubation on POD 2. Sternal wire complications, such as adherence and migration, added further complexity, underscoring the importance of preventive measures like Gore-tex patches to avoid direct graft-wire contact. Similar cases highlight these risks, including false aneurysms and wire migration into vital structures, necessitating vigilant long-term follow-up. This case emphasizes the critical role of advanced techniques and meticulous preoperative planning to ensure successful outcomes in high-risk reoperative aortic surgeries.

Conclusion: Careful evaluation of sternal wire risks, such as graft adherence and migration, is critical in reoperative sternotomies. Preventive strategies, including Gore-tex patches, and advanced techniques, like hypothermic circulatory arrest, are essential for positive outcomes.