A 66-year-old man with known chronic obstructive pulmonary disease and multiple spine surgeries was admitted to the local hospital with acute paraplegia, critical limb ischemia; no palpable pulses, no capillary filling, white color and cold legs, back pain, bradycardia and loss of consciousness. Echocardiography suspected pericardial fluid and CT showed aortic Stanford type A dissection with extension into the neck vessels, the descending aorta and with occlusion of spinal arteries, kidney arteries and both pelvic vessels (Fig. 1A and B). After air ambulance transfer and admission to our regional cardiac surgery center three hours after onset of symptoms, the patient underwent emergency surgery in a hybrid operating room after interdisciplinary planning between the cardiothoracic surgeons and interventional radiologists. At admission to our hospital the patient was still spontaneously breathing with a moderate metabolic acidosis as pH, BE and S-lactate was 7.3, − 0.4, and 1.1 mmol/l, respectively.

Aortic dissection type A (A) with subtotal occlusion of the descending and abdominal aorta (B) causing extensive distal organ malperfusion with subtotal occlusion of pelvic vessels

Under general anesthesia and following sternotomy, direct aortic cannulation with EOPA 22F cannula (Medtronic, Minneapolis, USA) was performed into the thru lumen guided by epiaortic ultrasound (VeriQ-C ®, Medistim, Oslo, Norway). CPB with deep hypothermia was established and the patient was cooled to 20 °C. During cooling, intraoperative angiography was performed through a sideline of the aortic cannula showing widespread dissection with remaining occlusion of the downstream abdominal aorta and run-off vessels (Fig. 2A). A Bolton Relay 34/200 mm stent graft (Bolton Medical, Florida, USA) was implanted upstream into the descending aorta via the left common femoral artery, which reestablished circulation to the lower extremities and the spinal cord (Fig. 2B). The covered part of the stent graft were placed close to the left subclavian artery, and only the bare string ended in zone 2, hence the left subclavian artery was not occluded. At 20 °C esophageal temperature the ascending aorta was opened and bilateral antegrade cerebral perfusion was commenced by direct cannulation into the aortic arch vessels. With luminal view of the aortic arch, the ascending aorta was replaced with a Vascutek Gelweave Ante-Flo 28/8 tube graft (Vascutek Terumo, Florida, USA).

A Antegrade angiography showing improved perfusion in the descending aorta, but remaining occlusion in the abdominal aorta. B Stent graft implantation in the descending aorta with the subsequent improvement of the abdominal aortic circulation

Following the distal anastomosis, downstream blood flow and systemic circulation was resumed via the sidearm of the prosthesis. During rewarming, repeated angiography showed renal artery stenosis limiting perfusion of the right kidney and dissection with subtotal occlusion of the iliac vessel on the right side. The endovascular procedure was terminated with stenting of both the right renal artery with a Everflex 7/40 mm (Medtronic, Minneapolis, USA) and the right external iliac artery with a Protege 10/40 mm (Medtronic, Minneapolis, USA), each with good angiographic results confirming patent distal run-off (Figs. 3A, B and 4A,  B).

Stenosis (A) of the right renal artery treated with a stent assuring good perfusion to the right kidney (B)

Occlusion of the right iliac artery before (A) and after stenting (B)

Following surgery, ventilatory support could be ended on the first postoperative day. The further postoperative course was uneventful without new onset of ischemic signs and few hours after waking up he gradually regained lower limb function. Following discharge to his local hospital, the patient underwent an extended rehabilitation program and could walk about after 3 months.