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Eur J Cardiothorac Surg 2005;27:159-161
© 2005 Elsevier Science NL

Case report

Surgical treatment of an aortic arch aneurysm without cardio-pulmonary bypass: endovascular stent-grafting after extra-anatomic bypass of supra-aortic vessels

^a Department of Cardio-Vascular Surgery, Rangueil University Hospital, 1 avenue Jean-Poulhès, 31059 Toulouse, Cedex, France
^b Department of Radiology, Rangueil University Hospital, Toulouse, Cedex, France

Received 22 April 2004; received in revised form 21 July 2004; accepted 27 July 2004.

^* Corresponding author. Tel.: +33 5 61 32 26 52; fax: +33 5 61 32 23 15. (E-mail: cdambrin{at}aol.com).

	Abstract

Top Abstract 1. Introduction 2. Case report 3. Discussion References

 
A 70-year-old patient presented a large saccular aneurysm involving the whole aortic arch. Because of a past history of left thoracotomy and a high co-morbidity profile, we opted for a combined strategy, consisting of an extra-anatomic bypass of the supra-aortic vessels, followed by the endovascular implantation of a covered thoracic stent-graft. Endovascular stent grafting of aortic arch aneurysm, after extra anatomic bypass of supra-aortic vessels, appears as an attractive alternative strategy for high surgical risk patients.

Key Words: Aortic arch aneurysm • Endovascular stent-grafting • Extra-anatomic bypass • Supra-aortic vessels

	1. Introduction

Top Abstract 1. Introduction 2. Case report 3. Discussion References

 
Endovascular procedures are new options for patients with high surgical risk during conventional operations. We report the case of a patient who underwent aortic arch reconstruction, consisting of an off-pump proximal reimplantation of the aortic arch vessels, combined with an endovascular stent graft, to exclude the entire aortic arch.

	2. Case report

Top Abstract 1. Introduction 2. Case report 3. Discussion References

 
A 70-year-old man with aortic arch aneurysm was referred to our hospital because of a rapid increase in the size of his aneurysm. This patient had a high co-morbidity profile including past history of left thoracophrenolaparotomy approach, severe chronic obstructive pulmonary disease, ischemic cardiopathy and poor left ventricular function. Pre-operative imaging demonstrated an aneurysm (diameter: 6.9cm) involving the stumps of the left primitive carotid, the sub-clavian artery and the isthmic aorta (Fig. 1). Endovascular stent-grafting was considered a reasonable approach.

View larger version (45K): [in this window] [in a new window]   Fig. 1. Diagram of aortic arch reconstruction.

As cervical and transcranial Doppler demonstrated the patency of the right subclavian artery and the circle of Willis, we decided not to perform any extra anatomic bypass of the left subclavian artery before the endovascular procedure.

Endovascular stent placement procedures were performed under general anaesthesia. The whole procedure was monitored with digital subtraction angiography and transoesophageal echocardiography. Via a left brachial artery approach, a 5-F 30cm long sheath with a distal marker (Cordis; Johnson and Johnson, Warren, NJ) was placed in the ostium of the left subclavian artery to allow aortography before stent positioning. To facilitate the progression of the stent graft in the angulated arch, a ‘pull through technique’ was used. After administration of 5000 U of heparin, the 24-F delivery system (Talent Medtronic) was inserted over the 2.60cm long guide wire (Back-Up Meier; Boston Scientific, Oakland, NJ) through a transverse arteriotomy of the right common femoral artery and advanced with fluoroscopic and TEE guidance. Three Talent prosthesis (135mm long and 44mm wide proximally and 40mm distally, not covered with polyester) consisted of a circumferential nitinol stent covered with low-profile polyester (Dacron; Medtronic). A latex balloon was inflated to model the nitinol stent (Fig. 1). Finally, an aortogram demonstrated complete aneurysm exclusion.

The postoperative course was uneventful. Even if we noted a mild difference of blood pressure between upper limbs, there were no signs of left upper limb ischemia. The patient was discharged after 7 days. A follow-up CT-scan, performed at 6 and 12 months, showed complete thrombosis of the aneurysmal sac (Fig. 2), which remained stable in size (maximal diameter: 6.8cm, 12 months after the procedure).

View larger version (120K): [in this window] [in a new window]   Fig. 2. Postoperative 3D CT reconstruction (SSD) 12 months after the procedure.

	3. Discussion

Top Abstract 1. Introduction 2. Case report 3. Discussion References

Authors have recently advocated treating distal aortic arch aneurysms with endovascular stent grafts implanted while deep hypothermic arrest [2,3]. More recently, others reported off-pump management of aortic arch aneurysm using an endovascular thoracic stent graft in high-risk patients [4–7].

The main problem of endovascular treatment of aortic arch aneurysm is often the lack of a sufficient landing zone for the thoracic stent graft [1,4]. Extra-anatomic bypass of supra-aortic vessels without cardio-pulmonary bypass is a solution [4,5,7]. When distal anatomoses are performed quickly or by side clamping the brachiocephalic and the left primitive carotid artery, anterograde selective cerebral perfusion is not necessary [8]. It is well known that bypassing the supra-aortic vessels from the ascending aorta without the aid of cardiopulmonary bypass in an atheromatous patient might be quite dangerous in term of embolism. In order to reduce the embolism risk, we first performed the distal anatomosis on the supra-aortic branches, then, we ligatured their origins and finally we performed the side to end anastomosis on the ascending aorta. Fortunately, our patient remained stable during the whole surgical procedure and did not present any neurological disorder.

The significant curvature of the aortic arch, which may cause a kink, is another problem [5,6]. Our patient received balloon dilatation after stent deployment in order to model the nitinol stent. Moreover, new generation of stent grafts, such as Matsui-Kitamura stent-graft or Talent prosthesis, are shaped especially to fit the curved portion of the aorta [6,8].

Last, but not least, the sub-clavian artery may be a problem when its ligature is impossible using a median sternotomy approach. On the control arteriogram, the aneurysm was not retro-opacified by the left sub-clavian artery, its occlusion was also not necessary. Postoperative control computed tomography demonstrated a thrombosed subclavian artery 6 and 12 months after the procedure. The aneurymal remained stable in size.

Due to the risk of ischemic complications, it is important to check the patency of the right vertebral artery and the Circle of Willis (by means of cervical and transcranial Doppler) before performing an exclusion of the left sub clavian artery. Our patient did not present any sign of upper limb ischemia. We also did not perform any extra anatomic bypass between the left carotid and subclavian arteries.

In conclusion, extra anatomic bypass of the aortic arch vessels, combined with endovascular stent-grafting is an alternative approach to conventional surgical procedures for patients considered at high surgical risk [4–8].

	References

Top Abstract 1. Introduction 2. Case report 3. Discussion References

 

1. Buth J, Penn O, Tielbeek A, Mersman M. Combined approach to stent-graft treatment of an aortic arch aneurysm. J Endovasc Surg 1998;5:329-332.[CrossRef][Medline]
2. Iguro Y, Arata K, Yamamoto H, Masuda H, Sakata R. A new concept in distal aortic arch aneurysm repair with a stent graft. J Thorac Cardiovasc Surg 2002;123:378-380.[Free Full Text]
3. Usui A, Tajima K, Nishikimi N, Ishigushi T. Implantation of an endovascular covered tent-graft for distal aortic arch aneurysm via midsternotomy under pigtail catheter guidance. Eur J Cardiothorac Surg 1999;16:356-358.[Abstract/Free Full Text]
4. Drenth DJ, Verhoeven EL, Prins T, Waterbolk TW, Boonstra PW. Relocation of supra-aortic vessels to facilitate endovascular treatment of a ruptured aortic arch aneurysm. J Thorac Cardiovasc Surg 2003;126:1184-1185.[Free Full Text]
5. Dietl CA, Kasirajan K, Pett SB, Wernly JA. Off-pump management of aortic arch aneurysm by using an endovascular thoracic stent graft. J Thorac Cardiovasc Surg 2003;126:1181-1183.[Free Full Text]
6. Czerny M, Fleck T, Zimpfer D, Kilo J, Sandner D, Cejna M, Lammer J, Wolner E, Grabenwoger M. Combined repair of an aortic arch aneurysm by sequential transposition of the supra-aortic branches and endovascular stent-graft placement. J Thorac Cardiovasc Surg 2003;126:916-918.[Free Full Text]
7. Schumacher H, Bockler D, Bardenheuer H, Hansmann J, Allenberg JR. Endovascular aortic arch reconstruction with supra-aortic transposition for symptomatic contained rupture and dissection: early experience in 8 high-risk patients. J Endovasc Ther 2003;10:1066-1074.[CrossRef][Medline]
8. Nitta Y, Tsuru Y, Yamaya K, Akasaka J, Oda K, Tabayashi H. Endovascular flexible stent grafting with arch vessel bypass for case of aortic arch aneursym. J Thorac Cardiovasc Surg 2003;126:1186-1188.[Free Full Text]

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