Eur J Cardiothorac Surg 2006;29:258-260
© 2006 Elsevier Science NL
Entire rerouting of the supraaortic branches for endovascular stent-graft placement of an aortic arch aneurysm
Roman Gottardi
a
,
Johannes Lammer
b
,
Michael Grimm
a
,
Martin Czerny
a
,
*
a Department of Cardiothoracic Surgery, University of Vienna Medical School, Vienna, Austria
b Department of Interventional Radiology, University of Vienna Medical School, Vienna, Austria
Received 31 August 2005;
received in revised form 31 October 2005;
accepted 2 November 2005.
* Corresponding author. Address: Waehringer Guertel 18-20, A-1090 Vienna, Austria. Tel.: +43 1 40 400 5643; fax: +43 1 40 400 5642. (Email: bypass{at}eunet.at).
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Abstract
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Conventional surgical repair of the aortic arch using cardiopulmonary bypass and deep hypothermic circulatory arrest still carries a substantial rate of mortality and morbidity. Endovascular stent-graft placement has developed as a safe and effective treatment modality in various diseases of the aorta. We report on the case of a 64-year-old male presenting with an aortic arch aneurysm involving the origin of the brachiocephalic trunk. A second thoracic aortic aneurysm was detected in the distal third of the descending aorta. The patient was treated by entire prosthetic rerouting of the supraaortic branches. Metachronously, the patient underwent endovascular stent-graft placement from the distal ascending aorta up the thoracoabdominal transition.
Key Words: Aortic arch • Stent-graft • Supraaortic vessels • Transposition
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1. Introduction
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Conventional surgical repair of the aortic arch using cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA) still carries a substantial rate of mortality and morbidity with mortality rates reported to be as high as 12.7% [1]. CPB is associated with a high systemic inflammatory response and substantial myocardial injury especially in high-risk subgroups [2]. Additionally, DHCA predicts a high incidence of permanent neurologic injury reported to be as high as 5.0% [3].
Endovascular stent-graft placement has developed as a safe and effective treatment modality in various diseases of the descending aorta [4–7]. In case of involvement of the aortic arch, innovative vascular surgical approaches to maintain cerebral perfusion have been developed to enable safe and effective endovascular aneurysm repair [8–10]. However, few reports are available reporting entire rerouting of the supraaortic branches for endovascular stent-graft placement as these patient cohort would have been sent home with blood pressure-lowering therapy without any surgical or interventional approach a few years ago.
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2. Clinical summary
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A 64-year-old male was admitted to our department with a history of surgical replacement of the aortoiliac axis due to a large aneurysm as well as bilateral femorocrural vein grafts due to popliteal aneurysms now presenting with rapid progression of more than 5 mm per 6 months of two known sequential thoracic aortic aneurysms. The first aneurysm involved the entire aortic arch and the second involved the distal third of the descending aorta.
The preoperative three-dimensional CT scan revealed a maximum diameter of 7.0 cm within the arch and 6.5 cm within the descending aorta (Fig. 1
). Due to significant comorbidities, especially due to a diffuse, surgically non-reconstructable coronary artery disease, a conventional surgical approach was deemed not suitable. Therefore, an alternative approach was chosen. After median sternotomy, the ascending aorta was exposed in the usual fashion. Then the innominate vein, the brachiocephalic trunk, the left common carotid as well as the left subclavian artery were circumferentially dissected and encircled with silastic tapes. After systemical heparinization with 80 IU per kilogram bodyweight, the ascending aorta was tangentially clamped and a longitudinal arteriotomy was performed. An anastomosis between the proximal portion of the inversed bifurcated Dacron prosthesis (16/8 mm Braun Unigraft, Melsungen) and the ascending aorta was performed with reinforcement of Teflon felt strips with a 4-0 Prolene running suture (Ethicon Inc., Somerville, NJ, USA). Consecutively, the left subclavian artery was clamped, transversely divided at its origin and an end-to-end anastomosis was performed with the initial branch of the bifurcated prosthesis with a 5.0 Prolene running suture. The branch was guided inferior to the innominate vein to avoid venous compression. The origin of the subclavian artery was oversewn with a 4.0 Prolene running suture.
Afterwards, the left common carotid artery was transversely divided at its origin. The proximal portion was oversewn with a 4.0 Prolene running suture. An end-to-side anastomosis between the initial branch of the bifurcated prosthesis and the left common carotid artery was performed with a 5.0 Prolene running suture. Having chosen this approach has several reasons. Sizing mismatch of the side branch of the prosthetic graft and the naturally rather small proximal common carotid artery is one reason. Diameter of the side branch and diameter of the naturally rather large proximal subclavian artery match nearly exactly. Furthermore, the situs after transposition is without tortuosity in this setting and, in our opinion, in areas of high flow an end-to-side anastomosis provides similar long-term patency rates as an end-to-end anastomosis.
Finally, the brachiocephalic trunk was transversely divided at its origin from the aortic arch, oversewn and an end-to-end anastomosis between the second branch of the bifurcated graft and the brachiocephalic trunk was performed with a 5.0 Prolene running suture. The second branch was guided superior to the innominate vein in order to avoid venous compression. The patient recovered uneventfully without any signs of neurologic injury. Fig. 2a shows CT scan after transposition of supraaortic branches.
After a recovery period of 21 days, the patient was taken to the interventional radiologists’ suite. After achievement of general anesthesia, the right common femoral artery was dissected free. Initially, a 5-French calibrated angiographic pigtail catheter was advanced via the right brachial artery into the aortic arch to reconfirm characterization of the morphology and extent of the aneurysm as well as to reconfirm patency of supraaortic rerouting. After systemic heparinization with 80 IU per kilogram bodyweight, a common femoral artery arteriotomy was performed and the delivery system was advanced under fluoroscopic guidance until the tip reached the origin of the brachiocephalic trunk. Afterwards, a 40/150 mm and a 40/100 mm Excluder prosthesis (Gore, Phoenix, AZ, USA) were inserted into the aortic arch. Completion angiography revealed regular patency of supraaortic branches as well as regular position of the stent-grafts. A small type Ia endoleak in the concavity of the aortic arch closed spontaneously within two weeks. Fig. 2b depicts the completion CT scan after 2 weeks.
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3. Comment
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This report is in line with previous successful alternative approaches in treating aortic arch aneurysms avoiding deep hypothermic circulatory arrest. The innovation lies within the aggressive rerouting of the entire arch and – to our knowledge – first complete transsection and end-to-end anastomosis to the brachiocephalic trunk.
The main advantage of this combined approach is the avoidance of extracorporeal circulation as well as hypothermic circulatory arrest. In this particular patient, two thoracic aortic aneurysms were detected. The first aneurysm involved the entire aortic arch and the second involved the distal third of the descending aorta. Interestingly, overstenting of intercostal arteries is not associated with an increased risk of paraplegia. Therefore, stent-graft placement of the entire thoracic aorta up to the thoracoabdominal transition may be performed liberally in most cases although this new approach itself is associated with further potential kinds of risk such as cerebral injury by embolization of atherosclerotic debris or detachment of soft plaques due to brisk manipulation of the stent-graft introducer in the aortic arch.
In summary, combined approaches have substantially contributed to extending indications of endovascular aneurysm repair up to the ascending aorta and a selective application of these techniques will enable safe and effective treatment of this highly selected subgroup of patients with aortic aneurysms by avoiding conventional arch aneurysm repair in deep hypothermia and circulatory arrest.
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Abstract
1. Introduction
