• Yusuke Takei, Ikuko Shibasaki, Kohei Suzuki, Shohei Miyazaki, Shotaro Hirota, Hirotaka Ohashi, Shunsuke Saito, and Hirotsugu Fukuda.
• Department of Cardiac and Vascular Surgery, Dokkyo Medical University Hospital, Mibu-Machi, Tochigi, Japan.
• Medicine (Baltimore). 2022 Jul 22; 101 (29): e29617e29617.

RationaleHemolytic anemia is a rare postoperative complication of aortic surgery, which may be caused by an excessively kinked graft that causes abnormal blood flow. It has been reported that 4-dimensional flow magnetic resonance imaging (4D flow MRI) can identify abnormal flow. Herein, we report the guidance of 4D flow MRI in performing the revision procedure for a patient with hemolytic anemia by evaluating abnormal blood flow based on this method.Patient ConcernsA 70-year-old woman presented with dizziness and fatigue. She had undergone total arch replacement with a frozen elephant trunk 5 years prior. We diagnosed hemolytic anemia caused by a kinked graft after total arch replacement.DiagnosisAlthough computed tomography findings revealed 3 lesions of the kinked graft at the ascending portion and cervical branches, 4D flow MRI findings showed that only the kinked graft at the ascending portion caused hemolytic anemia due to an elevated viscous energy loss around it.InterventionWe performed surgery to remove the kinked section instead of revision surgery consisting of total arch replacement.OutcomesThe patient's postoperative course was uneventful and there were no complications. Postoperative enhanced computed tomography findings showed that the repaired graft had an adequate length and smoothly curved shape. The 4D flow MRI findings revealed smooth flow in the ascending portion and decreased viscous energy loss.LessonsBased on the 4D flow MRI findings, we adopted a less invasive approach, repairing only the ascending portion of the graft, instead of performing revision surgery comprising total arch replacement.Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.

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