Hemodynamic oxygenator exchange-related effects during veno-venous extracorporeal membrane oxygenation for the treatment of acute SARS-CoV-2 respiratory distress syndrome.

Few patients with coronavirus disease 2019-associated severe acute respiratory distress syndrome (ARDS) require veno-venous extracorporeal membrane oxygenation (VV-ECMO). Prolonged VV-ECMO support necessitates repeated oxygenator replacement, increasing the risk for complications. Transient hypoxemia, induced by VV-ECMO stop needed for this procedure, may induce transient myocardial ischemia and acutely declining cardiac output in critically ill patients without residual pulmonary function. This is amplified by additional activation of the sympathetic nervous system (tachycardia, pulmonary vasoconstriction, and increased systemic vascular resistance). Immediate reinjection of the priming solution of the new circuit and induced acute iatrogenic anemia are other potentially reinforcing factors. The case of a critically ill patient presented here provides an instructive illustration of the hemodynamic relationships occurring during VV-ECMO support membrane oxygenator exchange.

Usefulness of postoperative high-sensitive troponin T measurement and implications for defining type 5 infarction.

BACKGROUND AND AIM OF THE STUDY: Guidelines indicate for type 5 myocardial infarction (MI) that postoperative troponin need not be exclusively ischemic but may also be caused by epicardial injury. Complexity arises from the introduction of high-sensitive troponin. This study attempts to contribute to the understanding of postoperative high-sensitive cardiac troponin T (hs-cTnT) increase. METHODS: The median enzyme increase of different cardiac operations was compared. Linear regression analyses were used to determine correlations between enzyme rise and independent parameters. Receiver-operating characteristics (ROC) served to evaluate the discriminatory power of enzyme rise in detecting ischemia and to determine possible thresholds. RESULTS: Among 400 patients, 2.8% had intervention-related ischemia analogous to type 5 MI definition. The median postoperative hs-cTnT/creatine kinase myocardial band (CK-MB) increase varied according to types of surgery, with highest increase after mitral valve and lowest after off-pump coronary surgery. After ruling out patients with preoperatively elevated hs-cTnT, regression analysis confirmed Maze procedure (p < .001), intra-pericardial defibrillation (p = .002), emergency intervention (p = .01), blood transfusions (p = .02), and cardiopulmonary bypass time (p = .03) as significant factors associated with hs-cTnT increase. In addition, CK-MB increase was associated with mortality (p = .002). ROC confirmed good discriminatory power for hs-cTnT and CK-MB with ischemia-indicating thresholds of 1705.5 ng/L (hs-cTnT) and 113 U/L (CK-MB) considering different types of operations. CONCLUSIONS: The Influence of the type of surgery and intervention-related parameters on hs-cTnT increase was confirmed. Potential thresholds indicating perioperative ischemia appear to be significantly elevated for high sensitive markers.

Total Endovascular Repair of Post-Trauma Ascending Aortic Pseudoaneurysm and Secondary Superior Vena Cava Syndrome.

BACKGROUND: Clavicular fracture or sternoclavicular luxation is observed in 10% of all polytrauma patients and is frequently associated with concomitant intrathoracic life-threatening injuries. Posterior sternoclavicular luxation is well known to induce underlying great vessels damage. The gold standard treatment usually is a combined orthopedic and cardiovascular surgical procedure associating vascular repair, clavicular open reduction, and internal fixation. METHODS: A 59-year-old wheelchair ridden, institutionalized woman, known for psychiatric disorder, severe scoliosis, malnutrition, and chronic obstructive pulmonary disease was admitted in our hospital for chronic chest pain 3 months after a stairway wheelchair downfall. A thoracic computed tomography (CT) scan revealed a voluminous ascending aortic pseudoaneurysm (63 × 58 mm, orifice 5 mm) consecutive to perforation following posterior sternoclavicular luxation. The patient refused all therapies and was lost to follow-up. Six months later, she was readmitted for a symptomatic superior vena cava syndrome. Thoracic CT scan revealed pseudoaneurysm growth with innominate vein thrombosis and superior vena cava subocclusion. Pseudoaneurysm orifice was stable. In the presence of symptoms with massive facial edema and inability to open her eyelids, the patient accepted an endovascular treatment. RESULTS: The procedure was performed under general anesthesia using both fluoroscopic and transesophageal echocardiographic guidance. Through a femoral arterial access, a 10-mm atrial septal defect occluder device was used to seal successfully the pseudoaneurysm orifice. The superior vena cava was then opened with a 26-mm nitinol high radial force stent through a femoral venous access. Postoperative course was uneventful. At 3-month follow-up, the patient remains symptom free and a CT scan confirmed pseudoaneurysm thrombosis and superior vena cava permeability. CONCLUSION: Post-traumatic sternoclavicular posterior luxation is a cause of great vessels and ascending aorta injuries. Minimally invasive endovascular approaches can be considered to treat vascular injuries and their consequences, especially in elderly patients and those at high risk for surgery.

Double-stage venous cannulation combined with Avalon® cannula for potential prolongation of respiratory ECMO in end-stage pulmonary disease.

Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is a treatment option to correct blood oxygenation in cases of severe respiratory failure. However, it is time-limited and, in cases of no- recovery, it is a bridge-to-lung transplant therapy. We report our experience of two patients waiting for emergency lung transplantation under VV-ECMO using the Avalon® cannula. Both presented signs of ECMO failure after prolonged support, i.e. increased hemolysis, decreased blood flow rate and increased negative pressure of the venous inflow line, leading to an inadequate systemic oxygenation. The addition of a second venous inflow line, by the insertion of another venous femoral cannula, significantly increased blood flow rate, decreasing both centrifugal pump rotation speed and negative pressure (suction) of the venous inflow line. These hemodynamic improvements, together with reduced blood consumption, were maintained during an additional week of ECMO support. Ultimately, both patients died from multi-organ failure due to the absence of available donor organs. Few cases having been described up until now, but the addition of a second venous drainage cannula to the Avalon® system could potentially improve hemodynamic parameters and, therefore, stabilize hypoxemic patients. This may be an option to gain time in long-lasting VV-ECMO support as a potential life-saving attempt.

Survival after surgical drainage of malignant pericardial effusion.

OBJECTIVES: Management of malignant pericardial effusion (PE) is complex. Cardiac surgeons are not necessarily familiar with or are challenged by the many underlying etiologies. Analyzing risk factors for mortality may help to estimate the benefit of surgery in high-risk patients. METHODS: Patients undergoing a surgical pericardiotomy for malignant PE, between 2001 and 2011, were included. The influence of tumor type, disease extension, intra-pericardial tumor infiltration on early mortality and long-term survival as well as freedom from symptoms after drainage, and the use of sclerosing agents on PE recurrence rates was analyzed. RESULTS: PE drainage was performed on 46 patients 12 ± 30 months after tumor diagnosis. Malignant diseases were lung cancers (50 %), breast cancers (15 %), lymphoma and leukemia (13 %), cancers of the digestive tract (13 %), and others (9 %). 80 % of patients were symptomatic and symptom relief was achieved in 65 %. Nobody died during surgery. Recurrence rate was 4 %. Early in-hospital mortality was 22 %. After 1 year, 29 % of patients were alive. Eleven patients (24 %) had a complete tumor regression. Metastatic spread (p < 0.001), pericardial infiltration (p = 0.02), and intra-pericardial Bleomycin (p = 0.01) injection were associated with increased mortality. Hematological malignancies had a better prognosis for survival. CONCLUSION: Surgical pericardiotomy is safe, associated with a low recurrence rate and symptom relief in the majority of dyspneic patients. Intra-pericardial Bleomycin may reduce recurrent effusion but does not ameliorate survival. Long-term survival rate was low with an increased mortality in cases of metastatic spreading, pericardial infiltration, and as the tumor of origin: breast cancers. Leukemic and lymphatic tumors have better prognosis.

Successful Surgical Pulmonary Embolectomy for Massive Perinatal Embolism after Emergency Cesarean Section.

Pregnant women are exposed to an increased risk for developing pulmonary embolism (PE), a main cause for maternal mortality. Surgical pulmonary embolectomy is one important therapeutic and potential life-saving armamentarium, considering pregnancy as a relative contraindication for thrombolysis. We present a case of a 36-year-old woman with massive bilateral PE after emergent caesarean delivery, requiring reanimation by external heart massage. The onset of massive intrauterine bleeding contraindicated thrombolysis and emergency surgical pulmonary embolectomy, followed by a hysterectomy, were preformed successfully. Acute surgical pulmonary embolectomy may be an option in critically diseased high-risk patients, requiring a multiteam approach, and should be part of the therapeutic armamentarium of the attending cardiac surgeon.

Percutaneous coronary interventions prior to coronary artery bypass surgery.

BACKGROUND AND AIM OF THE STUDY: Percutaneous coronary interventions (PCI) are frequently performed before coronary artery bypass graft (CABG) surgery. This study sought to evaluate postoperative outcomes, and incidence of recurrent target ischemia in vessels with prior PCI in patients who had PCI prior to CABG compared to only CABG patients. METHODS: A review included CABG patients operated from 2000 to 2012. PCI prior to CABG patients were compared with patients having had CABG on native coronary arteries. Demographic and risk factors, including hospital morbidity, mortality, and recurrent target vessel ischemia at follow-up (FU), were compared. Major end-points were statistical differences of postoperative morbidity and reintervention rates due to symptomatic graft failure or target vessel ischemia during FU. RESULTS: Twenty-four percent of 1669 isolated CABG patients had PCI prior to CABG, with an increasing percentage during recent years. Demographics, risk factors, comorbidities and mortality rates were similar. Incidence of postoperative hemorrhage (OR 1.9; 95% CI 1.1-3.2; p = 0.02), perioperative myocardial infarction rate (p = 0.02), neurological deficits (OR 3.5; 95% CI 1.2-9.7; p = 0.02) and re-intervention rate for symptomatic graft or target vessel occlusion were higher in pretreated patients (OR 1.8; 95% CI 1.1-3.0; p = 0.01). CONCLUSIONS: PCI prior to CABG increases the risk for postoperative morbidity. Increased postoperative hemorrhage could be attributed to ongoing double anti-platelet therapy.

Impact of preoperative central neurologic dysfunction on patients undergoing emergency surgery for type A dissection.

BACKGROUND: Preoperative central neurologic deficits in the context of acute type A dissection are a complex comorbidity and difficult to handle. The aim this study was to analyze this subgroup of patients by comparing them with neurologically asymptomatic patients with type A dissection. Results may help the surgeon in preoperative risk assessment and thereby aid in the decision-making process. METHODS: We reviewed the data of patients admitted for acute type A dissection during the period from 1999 to 2010. Associated risk factors, time to surgery from admission, extension of the dissection, localization of central nervous ischemic lesions, and the influence of perioperative brain protective strategies were analyzed in a comparison of preoperative neurologically deficient to nondeficient patients. RESULTS: Forty-seven (24.5%) of a total of 192 patients had new-onset central neurologic symptoms prior to surgery. Concomitant myocardial infarction (OR 4.9, 95% CI 1.6-15.3, P=0.006), renal failure (OR 5.9, 95% CI 1.1-32.8, P=0.04), dissected carotid arteries (OR 9.2, 95% CI 2.4-34.7, P=0.001), and late admission to surgery at >6 hours after symptom onset (OR 2.7, 95% CI 1.1-6.8, P=0.04) were observed more frequently in neurologically deficient patients. These patients had a higher 30-day in-hospital mortality on univariate analysis (P=0.01) and a higher rate of new postoperative neurologic deficits (OR 9.2, 95% CI 2.4-34.7, P=0.02). Neurologic survivors had an equal hospital stay, and 67% of them had improved symptoms. CONCLUSIONS: The predominance of neurologic symptoms at admission may be responsible for an initial misdiagnosis. The concurrent central nervous system ischemia and myocardial infarction explains a higher mortality rate and a more extensive "character" of the disease. Neurologically deficient patients are at higher risk of developing new postoperative neurologic symptoms, but prognosis for the neurologic evolution of survivors is generally favorable.

Trifecta and Carpentier Edwards aortic bioprostheses: Comparison of six years follow-up outcomes.

BACKGROUND: To compare mid-term clinical outcomes and hemodynamic performance of the stented pericardial Trifecta bioprosthesis for surgical aortic valve replacement (AVR) with a technically comparable commonly used surgical bioprosthesis. METHODS: Data from consecutive patients implanted with the TF or the Carpentier Edwards Magna Ease valve were retrospectively analyzed. Primary analysis was performed on a propensity score-matched cohort. Primary endpoints included the composite of death or reoperation and structural valve deterioration. The comparison also included echocardiographic assessments at one-week post-AVR and at the last documented follow-up. RESULTS: Two propensity score-matched groups of 170 patients each were identified from the overall population (n = 486). Incidence of postoperative mortality (2.9% vs. 7.1%, respectively, p = 0.08), and patient prosthesis mismatch (1.2% and 2.4%, p = 0.41) were similar. At mean follow-up of 5.84 (Trifecta) and 6.1 (Carpentier Edwards) years, the incidence of all-cause death/reoperation (15.3% vs. 15.9%, p = 0.88 for Trifecta and Carpentier Edwards, respectively) and structural valve disease (1.8% vs. 2.9%, p = 0.47) were similar. Overall, postoperative mean transvalvular pressure gradients were significantly lower in the Trifecta group than in the Carpentier Edwards group (7.7 ± 3.3 vs. 11.3 ± 3.6 mmHg, p < 0.01). Mean transvalvular gradient remained significantly lower through the last follow-up for small-sized Trifecta valves (19/21 mm; 10.5 ± 4.2 vs. 13.8 ± 5.9 mmHg, p = 0.039) but not for larger valves (10.3 ± 4.8 vs. 9.4 ± 3.5 mmHg, p = 0.31). CONCLUSION: The Trifecta valve is a valuable alternative to the Carpentier Edwards valve in terms of safety, hemodynamic performance, and mid-term durability. Smaller-sized valves provide additional clinical benefits, given their persistent hemodynamic advantages through mid-term follow-up.

Recovery of paraplegia after type B dissection due to spinal collateral recruitment.

Acute paraplegia could be a symptom of aortic dissection due to sudden compromise of arterial spinal cord blood supply. Complete spontaneous neurologic recovery is possible and was observed in the present case 3 hours after symptom onset. Spontaneous spinal cord reperfusion after acute type B dissection was probably due to two main mechanisms. Reperfusion of false lumen and collateral vascular network recruitment, recently confirmed by anatomic animal studies, serve as potential explanations. Favorable evolution of acute paraplegia after aortic dissection exists, but prognosis is uncertain, probably due to individual variable anatomic distribution of spinal cord blood supply.

Reduction aortoplasty: safe and durable treatment for borderline dilatation in selected patients.

BACKGROUND AND AIM OF THE STUDY: In aortic valve surgery, the management of ascending aortic dilatation is not clearly defined. Guidelines recommend replacement at diameters of 50 mm, but the handling of borderline dilatation has not been detailed. Reduction aortoplasty has been proposed as a less invasive and safe option in the case of a smaller dilatation above the sinotubular junction. METHODS: Between 1999 and 2009, reduction aortoplasties with or without external reinforcement associated with aortic valve surgery were performed in 82 patients. The ascending aortic diameter was measured echocardiographically at a mean follow up (FU) of 32 months (FU was 91% complete). RESULTS: The in-hospital mortality was 1.2%, and all patients were in NYHA class I or II. Echocardiography revealed a re-dilatation (> or = 5 mm) rate of 5.5%. One patient required reoperation. At univariate analysis, a preoperative dilatation >45 mm, persistent postoperative diameters >35 mm after reduction, and a younger age at the time of surgery (<65 years) were significant risk factors. Multivariate analysis confirmed the parameters for re-dilatation, and the area under the receiver operating curve was 0.85 for these three criteria. Mesh implantation, FU duration and bicuspid valve had no significant impact on outcome. CONCLUSION: Reduction aortoplasty is a less-invasive option to handle borderline supra-coronary aneurysms in the case of concomitant valve surgery, compared to aortic replacement. The mortality remained low, and equal to that for simple aortic valve replacement. A large preoperative aortic diameter and age < or = 65 years favored re-dilatation. Correct downsizing was technically demanding, but indispensable for long-term stabilization. Regard for these criteria could lead to numerous patients benefiting from this operative strategy, with good results.

Late migration of percutaneous bio-absorbable devices--a word of caution.

BACKGROUND: Closures of atrial septal defects or a patent foramen ovale (PFO) are increasingly performed percutaneously. The experience of late migration of a new bio-absorbable device is presented here, followed by conceptual discussion. METHODS: Six months post PFO closure with a BioSTAR® device a patient presented with chest pain. Echocardiography showed a hyperechogenic structure perforating the aortic wall. RESULTS: Surgical exploration showed a perforation of the ascending aorta by one metallic, non absorbable arm. This is the second case of late (>6 months) dislocation of the residual framework of the occluder. CONCLUSIONS: The overall incidence of perforation of cardiac structures due to secondary dislocation is low. However this complication exists and should kept in mind in symptomatic patients with new onset of chest pain, after percutaneous procedures. The concept of biodegradation, with residual, non absorbable metal braiding, should be reviewed, analyzing in particular long term results and incidence of secondary dislocation.

Cardiac arrest and COVID-19: inflammation, angiotensin-converting enzyme 2, and the destabilization of non-significant coronary artery disease-a case report.

BACKGROUND: The new ß-coronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) appears to exhibit cardiovascular pathogenicity through use of angiotensin-converting enzyme 2 (ACE2) for cell entry and the development of a major systemic inflammation. Furthermore, cardiovascular comorbidities increase susceptibility to SARS-CoV-2 infection and the development of a severe form of COronaVIrus Disease 2019 (COVID-19). CASE SUMMARY: We describe the case of a COVID-19 patient whose inaugural presentation was a refractory cardiac arrest secondary to the destabilization of known, non-significant coronary artery disease. Patient was supported by venoarterial extracorporeal life support. After 12 h of support, cardiac function remained stable on low vasopressor support but the patient remained in a coma and brainstem death was diagnosed. DISCUSSION: Myocardial injury is frequently seen among critically unwell COVID-19 patients and increases the risk of mortality. This case illustrates several potential mechanisms that are thought to drive the cardiac complications seen in COVID-19. We present the potential role of inflammation and ACE2 in the pathophysiology of COVID-19.

Case Report: Are We Witnessing an Increase of Chronic Ascending Aortic Dissection as a Collateral Effect to the COVID-19 Pandemic?

Background: The COVID-19 (coronavirus disease 2019) pandemic is reducing health care accessibility to non-life-threatening diseases, thus hiding their real incidence. Moreover, the incidence of potentially fatal conditions such as acute type A aortic dissection seems to have decreased since the pandemic began, whereas the number of cases of chronic ascending aortic dissections dramatically increased. We present two patients whose management has been affected by the exceptional sanitary situation we are dealing with. Case report: A 70-year-old man with chest pain and an aortic regurgitation murmur had his cardiac workup delayed (4 months) because of sanitary restrictions. He was then diagnosed with chronic type A aortic dissection and underwent urgent replacement of ascending aorta and aortic root. The delay in surgical treatment made the intervention technically challenging because the ascending aorta grew up to 80 mm inducing strong adhesions and chronic inflammation. The second case report concerns a 68-year-old woman with right lower-limb pain who was diagnosed with deep vein thrombosis. However, a CT scan to exclude a pulmonary embolism could not be realized until 5 months later because of sanitary restrictions. When she eventually got the CT scan, it fortuitously showed a chronic dissection of the ascending aorta. She underwent urgent surgery, and the intervention was challenging because of adhesions and severe inflammation. Conclusion: Delayed treatment due to sanitary restrictions related to COVID-19 pandemic is having a significant impact on the management of potentially life-threatening conditions including type A aortic dissection. We should remain careful to avoid COVID-19 also hitting patients who are not infected with the virus.

Type A aortic dissection in aneurysms having modelled pre-dissection maximum diameter below 45 mm: should we implement current guidelines to improve the survival benefit of prophylactic surgery?

OBJECTIVES: Current guidelines recommend prophylactic replacement of the ascending aorta at an aneurysmal diameter of >55 mm to prevent acute Type A aortic dissection (TAAD) in non-Marfan patients. Several publications have challenged this threshold, suggesting that surgery should be performed in smaller aneurysms to prevent this devastating disease. We reviewed our experience with measuring aortic size at the time of TAAD to validate the existing recommendation for prophylactic ascending aorta replacement. METHODS: All patients who had been admitted for TAAD to our emergency department from 2014 to 2019 and underwent ascending aorta replacement were included. Marfan patients were excluded. The maximum diameter of the dissected aorta was measured preoperatively using CT scan. We estimated the aortic diameter at the time of dissection to be 7 mm smaller than the measured maximum diameter of the dissected aorta (modelled pre-dissection diameter). RESULTS: Overall, 102 patients were included. Of these, 67 were male (65.6%) and 35 were female (34.4%), and the cohort's mean age was 65 ± 12.1 years. In addition, 66% were treated for arterial hypertension. The mean maximum modelled pre-dissection diameter was 39.6 ± 4.8 mm: 39.1 ± 5.1 mm in men and 40.7 ± 2.8 mm in women (P = 0.1). The cumulative 30-day mortality rate was 19.6% (20/102). CONCLUSIONS: TAAD occurred at a modelled aortic diameter below 45 mm in 87.7% of our patients. Therefore, the current aortic diameter threshold of 55 mm excludes ∼99% of patients with TAAD from prophylactic replacement of the ascending aorta. The maximum diameter of the ascending aorta warrants reappraisal and this parameter should be a distinct part of a personalized decision-making process that also takes into account age, gender and body surface area to establish the surgical indication for preventive aorta replacement aimed to improve the survival benefit of this procedure.

Therapy of acute massive pulmonary embolism associated with Klippel-Trenaunay syndrome.

Acute massive pulmonary embolism (PE) is a life-threatening event. Before the era of cardiopulmonary bypass, acute pulmonary embolectomy had been historically attempted in patients with severe hemodynamic compromise. The Klippel-Trenaunay syndrome (KTS) represents a significant life-long risk for major thromboembolic events. We present two young patients with Klippel-Trenaunay syndrome who survived surgical embolectomy after massive PE and cardiopulmonary resuscitation, with good postoperative recovery. Even though the role of surgical embolectomy in massive PE is not clearly defined, with current technology it can be life saving and can lead to a complete recovery, especially in young patients as described in this study.

Early results of the Resilia Inspiris aortic valve in the old age patients - a retrospective comparison with the Carpentier Edwards Magna Ease.

Introduction: The Inspiris Resilia aortic valve® (INSPIRIS) is a pericardial bio-prosthesis with a new sterilization procedure that shows promising results in terms of reduced calcification. Methods: The 30-day mortality and morbidity were analyzed, comparing the INSPIRIS implanted between May 2017 and the end of January 2019, with its "predecessor", the Carpentier-Edwards Perimound Magna Ease (ME). Echocardiography was performed one-week after surgery. 125consecutively operated patients were included (59 INSPIRIS, 66 ME). Results: One patient in the ME group died and one patient in the INSPIRIS group had a complicated postoperative course due to right heart failure. Two patients (one INSPIRIS, one ME patient) suffered a perioperative stroke. The hemodynamic evaluation shows an effective reduction of mean transvalvular pressure gradients after surgery in both groups. INSPIRIS tended to have lower trans-prosthetic pressure gradients (9 mm Hg, Interquartile range [IQR] 11-7 mm Hg versus 12 mm Hg, IQR 15-9 mmHg; P = 0.001), reduced trans-prosthetic blood flow acceleration (209 cm/s, IQR 220-190 cm/s versus227 cm/s, IQR 263-191 cm/s; P = 0.003) and increased permeability indices (57%, IQR 67%- 47% versus42%, IQR 48%-38%; P8%; P < 0.001). Conclusion: There are only few clinical data available from INSPIRIS, and the present analysis confirms good results initial postoperatively with a tendency towards possibly improved hemodynamics compared to ME.

First Results of the Single Heartstring Aortotomy for Multiple Off-Pump Vein Grafts: A Case Series.

To validate the technique of the single Heartstring aortotomy for multiple off-pump venous bypass grafts (described in 2015), the results of a 38-month follow-up study of 18 patients, including high-risk patients, are presented. No early deaths or cardiac or cerebral complications occurred. During the follow-up period, 2 patients died of non-cardiac causes, and 3 developed coronary ischemia. Ischemia occurred due to late graft occlusion in 2 patients, both of whom had normal postoperative courses and correct graft flow. The presence of acute symptoms 24 months after surgery in these patients indicated that technical graft failure was unlikely. This safe technique combines the advantages of simple and reproducible revascularization, the off-pump approach, and minimal aortic manipulation.

Traumatic brachiocephalic trunk dissection of a bovine arch.

Aortic dissections after deceleration traumas are mainly located in the region of the proximal descending thoracic aorta. Less common are brachiocephalic trunk ruptures, which are not automatically amenable to an endovascular treatment. We present a poly-traumatized patient with an intimal tear at the origin of the brachiocephalic tunk with intramural haematoma extension to the ascending aorta. In addition, the left common carotid artery originated from the proximal brachiocephalic trunk, forming a 'bovine arch'. Aortic arch and supra-aortic arteries were successfully replaced. The case demonstrates the importance of an individualized treatment in complex intrathoracic vascular injuries in poly-traumatized patients, including a careful risk assessment.