Eur J Cardiothorac Surg 1999;16:356-358
© 1999 Elsevier Science NL
Implantation of an endovascular covered stent-graft for distal aortic arch aneurysm via midsternotomy under pigtail catheter guidance
Akihiko Usuia,
Kazuki Tajimab,
Naomichi Nishikimic,
Tsuneo Ishiguchid
a Department of Thoracic Surgery, Nagoya University School of Medicine, Nagoya, Japan
b Department of Cardiac Surgery, Nagoya second Red-Cross Hospital, Nagoya, Japan
c Department of First Surgery, Nagoya University School of Medicine, Nagoya, Japan
d Department of Radiology, Nagoya University School of Medicine, Nagoya, Japan
Corresponding author. 65 Tsurumai, Showa-ku, Nagoya 466-0065, Japan. Tel.: +81-52-744-2376; fax: +81-52-744-2383
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Abstract
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We implanted an endovascular covered stent-graft for distal aortic arch aneurysm involving the left subclavian artery in 12 cases. A stent-graft was delivered just below the aneurysm via aortotomy with direct vision using a 12 F delivery sheath under guidance of a pigtail catheter placed via the groin artery. The proximal anastomosis of the stent-graft was performed with inclusion technique, and the aortotomy was then closed with it. This technique reduces operative damage by eliminating distal anastomosis and should reduce operative mortality and morbidity.
Key Words: Stent graft • Aortic arch aneurysm • Pigtail catheter
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1. Introduction
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Approach and exposure of the distal aortic arch just below left subclavian artery is difficult due to its location, and surgery for distal arch aneurysm has carried the risk of high morbidity and mortality. Implantation of an endovascular covered stent-graft via midsternotomy is one of methods to reduce operative damage by eliminating distal anastomosis. This technique has been previously described by Kato and colleagues [1]. We have applied an endovascular covered stent-graft for distal aortic arch aneurysm involving left subclavian artery to 12 cases since January 1997. We made some modifications to improve the original techniques based on our case experiences.
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2. Methods
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2.1. Patient material
All patients were assigned to this study under informed consent. We usually implant an endovascular stent-graft to relatively high-risk patients. There were 12 such patients from January 1997 until September 1998, 11 of whom were true aneurysms and one a chronic type B dissection. They were just half of the surgical cases of distal aortic arch aneurysm encountered in this period. All but one patient had preoperative complications as follows: brain infarction in 4, myocardial infarction and angina pectoris in 2, left side pleural adhesion in 2, advanced age (82 years) in 1, severe obesity in 1, and bilateral carotid artery stenosis in 1. Combined procedures were total aortic arch replacement in 1 case, and aortocoronary bypass grafting in 2. The average operation time was 364 min and retrograde cerebral perfusion (RCP) time was 42 min. Cardiopulmonary bypass time averaged 211 min. All patients awoke within 12 h after the operation. Nine patients were extubated within 24 h. In half of the cases, no blood transfusion was used. There was no mortality, but cerebral infarction and paraplegia were complications in 1 case. The average follow-up period was 17±5, ranging from 8 to 28, months. Eleven patients were followed up for more than 1 year. There was no evidence of endovascular leakage, and all 12 aneurysms were thrombosed completely on an enhanced chest computed tomography scan before discharge and 6 months thereafter (Fig. 1).
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Fig. 1. Enhanced chest CT findings before and after implantation of an endovascular covered stent-graft. (A) Enhanced chest CT before operation. (B) Enhanced chest CT 1 month after operation.
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2.2. Preparation for endovascular covered stent-graft
The endovascular covered stent-graft procedure has been approved by the Nagoya University Ethical Committee. A stainless self-expanding double-linked 8-bend Z stent is made ourselves for each case. Its diameter is 40% larger than that of the descending aorta. The endovascular covered stent-graft is assembled in the operation room. The Z stent is inserted into an ultrathin woven Dacron graft (Ubekosan, Ube, Japan), with a diameter approximately 20% larger than that of the descending aorta. They are sutured together at each end of the eight bends. Then the woven Dacron graft is flipped over and the Z stent is inserted into a 12 F delivery sheath (Greenfield vena cava filter, Boston Science Corp., MA, USA) with an extra-hard guide-wire (Amplatz super-stiff guidewire, Boston Science Corp.) in its center. The woven Dacron graft is then flipped back to the normal position.
2.3. Operative procedure
The patient is placed in the supine position, and the pigtail catheter is inserted via the groin artery and placed at the distal aortic arch (Fig. 2). A midsternotomy is performed and a cardiopulmonary bypass is applied with bicaval, ascending aortic cannulations and left ventricular venting. The patient is cooled down to 20°C of the nasopharyngeal temperature, RCP is started, and the heart is arrested with retrograde cardioplegia without aortic clamping. The anterior wall of an aortic arch is opened transversely. Then the inside of the aneurysm is inspected, and the pigtail catheter is grasped. The length of the aneurysm is measured by the marker on the pigtail catheter, which is then inserted into an endovascular covered stent-graft using the guide-wire inside it. Then the endovascular covered stent-graft is inserted into the descending aorta via aortotomy by guiding the pigtail catheter (Fig. 1). The Z stent is released and the 12 F delivery sheath is removed using a solid Teflon rod just below the aneurysm. The graft is trimmed according to the shape of the proximal anastomosis site. Proximal anastomosis on the posterior wall is performed with an inclusion technique, and the aortotomy is then closed by fixing the anterior wall of the graft. Deairing of the aorta is performed by venting the ascending aortic cannulae, and antegrade perfusion is resumed.
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Fig. 2. A pigtail catheter is inserted via the groin artery and is placed at the distal aortic arch. The pigtail catheter is inserted into an endovascular covered stent-graft using the guidewire placed inside. Then the endovascular covered stent-graft is inserted into the descending aorta under pigtail catheter guidance.
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3. Discussion
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We used a knitted Dacron graft (Gelsheal, Vascutek, Scotland, UK) with polytetrafluoroethylene (PTFE) covered stent-graft without pigtail catheter guidance in the first 6 cases. At that time, we experienced some difficulty in inserting the graft into the descending aorta. There was also some concern about releasing debris from the aneurysmal thrombus. A bulky graft would also interfere with inspection of the aneurysm and make it difficult to decide the place for Z stent release. There actually was a case complicated with a minor cerebral infarction. Following these experiences, we applied an ultrathin woven Dacron graft under pigtail catheter guidance. When an endovascular covered stent-graft is implanted for a distal aortic arch aneurysm, the key points are how to guide the stent-graft into the descending aorta, and how to decide the place for the stent to be delivered. Forcible insertion of a stent-graft may cause an intimal tear, so as to cause an aortic dissection, and blind insertion may misplace it into the false lumen in patients with a dissecting aneurysm. Smooth and harmless insertion of a stent-graft and correct delivery are possible under pigtail guidance even in a patient with a dissecting aneurysm. A self-expanding Z stent should be delivered into the descending aorta just below the aneurysm. Deep insertion of a stent-graft interrupts blood flow of more intercostal arteries and increases the risk of paraparesis or paraplegia. Conversely, its insufficient insertion may lead to eventual dislocation. An ultrathin woven Dacron graft does not obstruct direct inspection, so the self-expanding Z stent can be delivered to exactly the right place. We believe that the implantation of an ultrathin woven Dacron graft-made stent-graft under pigtail catheter guidance should reduce the chance of arterial injury and spinal cord injury and may improve surgical outcome.
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References
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Kato M., Ohnishi K., Kaneko M., et al. New graft-implanting method for thoracic aortic aneurysm or dissection with a stented graft. Circulation 1996;94(suppl II):II188-II193.
Received January 7, 1999;
received in revised form June 14, 1999;
accepted June 14, 1999.
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Top
Abstract
1. Introduction
