Cabrol Procedure in Complex Aortic Root Reconstruction: A Case Series of Three Young Patients With Acute Aortic Syndrome

Abstract

Acute aortic dissection is a rare but life-threatening syndrome, being accompanied by a mortality rate of 1%-2% per hour after the onset of symptoms if they remain untreated. The definitive therapy for type A acute aortic dissection is considered to be emergency surgery. However, the optimal method for aortic root reconstruction has been a controversial issue. This study presents three cases of acute thoracic aortic dissection (TAD) accompanied by complicated aortic root anatomy. These critical conditions were managed successfully with the Cabrol procedure. In this procedure, the coronary ostia are anastomosed to a second graft in an end-to-end fashion, which is then connected side to side with the ascending aorta. A 2-year follow-up of patients showed they had no new signs or symptoms or reemergence of them during this period. Follow-up transthoracic echocardiography (TTE) and computed tomography angiography (CTA) of the aorta showed no evidence of obstruction or complications of Cabrol and aortocoronary anastomosis. Although the modified Bentall procedure using coronary ostial aortic "buttons" may produce superior results and currently represents the standard of care for aortic root reconstruction, the Cabrol procedure can be considered a clinically valuable rescue procedure in patients whose management becomes more complicated due to anatomic difficulties.

Keywords: acute dissection aorta; cardiac surgery; case series; interventional cardiology.

FIGURE 1

Transverse section of the ascending aorta in our first case. (A) One true lumen, two acute false lumens, and chronic false lumen in the ascending aorta. (B) False lumens were obliterated using the double sandwich technique, employing a strip of Teflon felt.

FIGURE 2

Cabrol procedure. (A) The Classic Cabrol procedure was performed for cases 1 and 2, in which the Cabrol tube graft was connected to the medial and left side of the ascending aorta tube graft. (B) for case 3, the modified Cabrol procedure was carried out, and the Cabrol tube graft was anastomosed to the lateral and right side of the ascending aorta tube graft. LMCA stands for left main coronary artery, and RCA stands for right coronary artery.

FIGURE 3

(A) Cabrol tube on the transthoracic short axis parasternal view (white arrow), (B) transesophageal echocardiography shows a textured tube graft (Cabrol anastomosis) in the anterior side of the ascending aorta (yellow arrow). (C) Doppler image of coronary diastolic flow (white arrow) through the cabrol tube graft on the transesophageal echocardiography. (D) Coronary CT angiography performed 35 months post‐surgery reveals a patent Cabrol anastomosis to the ascending aorta conduit (red arrowhead), a patent Cabrol to the left main coronary artery connection (red asterisk), and patent coronary arteries.

FIGURE 4

CT angiography of the Aorta reveals modified Cabrol tube graft (blue arrow), tube graft of Bentall procedure in ascending aorta position, hemiarch replacement (green arrows), and previous descending thoracic aorta tube graft (red asterisk).

FIGURE 5

We created two perpendicular ovoid punch holes on the Cabrol graft tube and the aortic conduit and then sewed these two incisions together.