Re-Entry to the Mediastinum when the Ascending Aorta is Adherent to the Sternum: A Two Stage Sternotomy Approach

Re-entry to the mediastinum, when the ascending aorta aneurysm is adherent to the sternum is characterized by high risk of aneurysm rupture during sternum opening. In such cases, often cardiopulmonary bypass via peripheral vessels is institute and re-entry will be done in deep hypothermia and circulatory arrest. However, long CPB time and adhesion dissection when performed while the patient is heparinized, is demanding and notably time consuming. Also, post operative recovery might be complicated, including, prolonged intubation, kidney dysfunctionand numerous blood transfusions. In order to reduce both risks of aneurysm rupture during resternotomy and those related to prolonged CPB time, we present a surgical approach consisting of a two-stage sternotomy to avoid the risky zone, and extra-anatomic epiaortic vessels anastomoses. This technique presents several advantages: adhesion dissection and access to the heart before the heparin is administrated, simplifying surgical field preparation shorter CPB time, and circulatory arrest.