Open surgical conversion after debranching thoracic endovascular aortic repair for chronic aortic dissection in a young patient with connective tissue disease

Open surgical conversion after debranching thoracic endovascular aortic repair in young patients with connective tissue disease is a formidable challenge, posing a high risk of cerebral air embolism. We report a case and describe a novel neuroprotection strategy to mitigate this risk. A 41-year-old female with connective tissue disease presented with a rapidly expanding 62-mm descending thoracic aortic aneurysm, five years after an initial debranching thoracic endovascular aortic repair. Following a staged oophorectomy for a borderline ovarian tumour, she underwent definitive open aortic repair. The operation was performed via a left thoracotomy with the patient under deep hypothermic circulatory arrest. To prevent air entry into the non-anatomical arch vessels, retrograde cerebral perfusion was initiated to establish positive venous pressure before the institution of selective antegrade cerebral perfusion. The stent graft was subsequently explanted, and the aorta was reconstructed. The procedure was completed successfully. The patient's postoperative course was uneventful, and she was discharged without any neurologic deficits. The proactive use of retrograde cerebral perfusion prior to selective antegrade cerebral perfusion is a simple, safe and effective technique to prevent catastrophic cerebral air embolism during complex open conversions. This case also highlights concerns regarding the long-term durability of thoracic endovascular aortic repair in young patients with connective tissue disease.