Eur J Cardiothorac Surg 2006;29:611-612
© 2006 Elsevier Science NL
A hybrid technique of aortic arch branch transposition and antegrade stent graft deployment for complete arch repair without cardiopulmonary bypass
George Matalanis
*
,
Manoj Durairaj,
Mark Brooks
Department of Cardiac Surgery, Austin Hospital, Studley Road, Heidelberg, Melbourne, Vic. 3084, Australia
Received 22 September 2005;
received in revised form 8 December 2005;
accepted 16 December 2005.
* Corresponding author. Tel.: +61 3 9457 1071; fax: +61 3 9457 6320. (Email: gmatalan{at}bigpond.net.au).
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Abstract
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We describe a minimally invasive technique for complete aortic arch repair without cardiopulmonary bypass. A 77-year-old man with severe obstructive airways disease presented with aneurysmal disease of his aortic arch. Through a median sternotomy and the application of a side-biting clamp, the common trunk of a bifurcation Dacron graft was anastomosed to the ascending aorta. The limbs of the graft were anastomosed to the innominate and left common carotid arteries, respectively. The left subclavian artery was ligated. Two endoluminal stent grafts were deployed via a side arm in the Dacron graft, covering the whole arch. Completion angiography and transesophageal echocardiography revealed excellent seating of both stent grafts, with no endoleaks. The patient had a rapid, uneventful post-operative recovery. Follow-up CT scanning revealed complete exclusion of the arch aneurysm.
Key Words: Aneurysm • Aortic arch • Off-pump • Stent graft
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1. Introduction
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Standard surgical repair of arch aneurysms involves cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA), usually with some form of cerebral perfusion. This method still carries significant risks. Endoluminal stent grafting (ELG) has been used to treat thoracic and abdominal aortic aneurysms effectively, which is less invasive and has been associated with lower morbidity and mortality [1]. However, standard ELG techniques cannot be used in the cerebral vessel bearing part of the arch. We describe a minimally invasive technique for endovascular stent grafting of the whole aortic arch without the need for CPB.
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2. Patient
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A 77-year-old man with severe obstructive airways disease was incidentally discovered having aneurysmal disease of his aortic arch. The pre-operative spiral computed tomographic (CT) scan showed two saccular arch aneurysms, the largest measuring 5.7 cm (Fig. 1A). The carotid arteries were patent and the circle of Willis intact, indicating that the left subclavian artery (LSA) could be safely occluded. Duplex scanning did not reveal any significant atherosclerosis in the supraaortic branches.
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Fig. 1. (A) The bifurcation graft is sewn onto the ascending aorta; (B) two endoluminal stent grafts deployed via the side arm in the bifurcation graft; (C) complete coverage of the arch aneurysms.
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3. Technique
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The chest was opened through a median sternotomy with extension into the left neck. After heparinisation, a side-biting clamp was applied to the ascending aorta. The trunk of a 20 mmx 10 mm bifurcation Intergard® graft (Intervascular, Cedex, France) was anastomosed to the ascending aorta. A side hole was made in the trunk to which an extra length of 10 mm Intergard® graft was anastomosed. This side graft would be utilised later for insertion of the stent graft. Cerebral monitoring, such as transcranial Doppler, was not available at the time of the procedure but has subsequently been instituted. The left common carotid artery was clamped proximal to its bifurcation in the neck and also at its origin from the arch. It was amputated immediately distal to the arch and was anastomosed to one of the limbs of the bifurcation graft. The stump of the left common carotid artery (LCA) was then ligated. A similar procedure was carried out for the innominate artery.
Two 34-mm ELGs (Zenith, William Cook, Australia) were deployed via the side arm in the Dacron graft with the aid of an image intensifier and transesophageal echo (TEE) (Fig. 1B). No systemic hypotension was used during deployment as this is not a prerequisite in the deployment of the Zenith® Cook ELG. The proximal end of the first graft was positioned in the ascending aorta, just beyond the bifurcation graft takeoff and 3 cm proximal to the oversewn origin of the innominate artery. The distal end of the second graft was positioned in the proximal descending aorta, 5 cm beyond the aneurysm neck and the left subclavian origin. This also allowed at least three-stent-width overlap between the two ELGs, to prevent future slippage. The base of the LSA was ligated to prevent backflow in the LSA causing a Type II endoleak (Fig. 1C).
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4. Results
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Completion angiography and TEE revealed excellent seating of both ELGs with no perfusion of the aneurysm. The patient was extubated on the first post-operative day, with no cerebrovascular, renal or respiratory complications. CT angiography after one month revealed complete exclusion of the aneurysm (Fig. 2
).
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5. Discussion
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In our technique, the whole of the arch and even the distal ascending aorta can be covered. Separate grafts are applied to the two main cerebral branches, avoiding the reliance on a single inflow. The extra side arm graft allows for an easy and haemostatic method of introducing the delivery device, with no reliance on adequacy of the peripheral vascular tree.
An extra-anatomic technique has been described where an interposition graft is placed from left to right carotid, across the midline of the neck, and then onto the left subclavian artery [2]. This renders cerebral inflow entirely dependent on the innominate artery. In addition, it allows only partial coverage of the arch. Akasaka et al. [3] also used an ELG to cover the arch following extra-anatomical bypass grafting of the arch vessels. Their technique, however, utilised left heart bypass and selective cerebral perfusion. A similar technique to that of ours was described by Kato et al. [4]. However, they did not transpose the innominate artery, instead, they bypassed the left carotid and left subclavian arteries, thus they could only cover the mid and distal arch. Also, in Kato's technique, the ELG was inserted directly into the common trunk of the bifurcation graft rather than via a side limb.
We believe that the technique we have described for arch branch relocation to the ascending aorta and antegrade stent graft deployment via median sternotomy, without bypass or circulatory arrest, offers a minimally invasive technique for the complete treatment of aortic arch aneurysms.
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References
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- Mitchell RS, Dake MD, Semba CP, Fogarty TJ, Zarins CK, Liddle RP, Miller DC. Endovascular stent graft repair of thoracic aortic aneurysms. J Thorac Cardiovasc Surg 1996;111:1054-1062.[Abstract/Free Full Text]
- Bergeron P, De Chaumaray T, Gay J, Douillez V. Endovascular treatment of thoracic aortic aneurysms. J Cardiovasc Surg (Torino) 2003;44:349-361.[Medline]
- Akasaka J, Tabayashi K, Saiki Y, Oda K, Kumagai K, Iguchi A. Stent grafting technique using Matsui-Kitamura (MK) stent for patients with aortic arch aneurysm. Eur J Cardiothorac Surg 2005;27(4):649-653.[Abstract/Free Full Text]
- Kato M, Kaneko M, Kuratani T, Horiguchi K, Ikushima H, Ohnishi K. New operative method for distal aortic arch aneurysm: combined cervical branch bypass and endovascular stent graft implantation. J Thorac Cardiovasc Surg 1999;117:832-834.[Free Full Text]
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Abstract
1. Introduction
