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Eur J Cardiothorac Surg 2007;31:623-627. doi:10.1016/j.ejcts.2006.12.030
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved

Mid-term results of supraaortic transpositions for extended endovascular repair of aortic arch pathologies

^a Department of Cardiothoracic Surgery, University of Vienna Medical School, Vienna, Austria
^b Department of Interventional Radiology, University of Vienna Medical School, Vienna, Austria
^c Department of Cardiovascular Surgery, Hospital Hietzing, Vienna, Austria

Received 21 September 2006; received in revised form 8 December 2006; accepted 13 December 2006.

^_* Corresponding author. Address: Waehringer Guertel 18-20, A-1090 Vienna, Austria. Tel.: +43 1 40 400 5643; fax: +43 1 40 400 5642. (Email: martin.czerny{at}meduniwien.ac.at).

	Abstract

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Comment Appendix A References

 
Objective: To evaluate mid-term results of supraaortic transpositions for extended endovascular repair of aortic arch pathologies. Methods: From October 2002 to July 2006, 27 patients (mean age 72 years) with aortic arch diseases were treated (arch aneurysms n = 18, type B dissections n = 5, perforating ulcers n = 4). Strategy for distal arch disease was autologous sequential transposition of the left carotid artery and of the left subclavian artery in 17 patients. Strategy for entire arch disease was total supraaortic rerouting using a reversed bifurcated prosthesis in 10 patients. Endovascular stent-graft placement was performed metachronously thereafter. Results: Two in-hospital deaths occurred (myocardial infarction on the day prior to discharge n = 1, rupture while waiting for stent-graft placement n = 1). At completion angiography, all reconstructions were fully patent. Four patients had small type Ia endoleaks, two of them resolving spontaneously. Mean follow-up is 15 months (1–43 months). Three late deaths occurred (myocardial infarction n = 2, sudden unknown death n = 1). One-year survival was 83% and 3-year survival was 72%, respectively. Redo stent-graft placement was performed in one patient after 25 months (type III endoleak). The remaining patients had normal CT scans with regular perfusion of the supraaortic branches without any signs of endoleaks. Conclusions: Mid-term results of alternative treatment approaches in elderly patients with aortic arch pathologies are satisfying. Extended applications provide safe and effective treatment in patients at high risk for conventional repair.

Key Words: Aortic arch aneurysm • Supraaortic transposition • Endovascular stent-graft

	1. Introduction

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Comment Appendix A References

 
Superiority of endovascular stent-graft placement as compared with medical or conventional surgical therapy has been proven for various indications of acute and chronic pathologies of the thoracic aorta [1–6]. Aortic arch pathologies have been a domain of conventional surgical therapy if the risk–benefit ratio justified treatment [7–9]. Recently alternative approaches have been developed enabling treatment in patients not suitable for conventional arch surgery [10–15]. Thereby options were opened to a broader patient cohort.

The aim of this study was to evaluate mid-term results of supraaortic transpositions for extended endovascular repair of aortic arch pathologies.

	2. Patients and methods

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Comment Appendix A References

 
Between October 2002 and July 2006, 27 patients with aortic arch pathologies were treated with a combined vascular–endovascular approach at our department. All patients had substantial comorbidities thereby prohibiting conventional aortic arch surgery. Patient demographics are shown in Table 1 . All patients underwent risk stratification according to EuroSCORE guidelines [16]. EuroSCORE is known as a widespread preoperative risk stratification system encomprising demographic, cardiac-related as well as surgery-related variables. Both, additive and logistic values were collected as logistic EuroSCORE has been reported to be a better risk predictor in high-risk patients [17].

In patients undergoing autologous transposition of the supraaortic branches, an upper hemistermotomy was chosen and the skin incision was extended parallel to the upper margin of the left clavicula in order to achieve sufficient mobilization of the left common carotid and the left subclavian artery up to an extrathoracic level. In patients undergoing total arch rerouting, a full median sternotomy approach was chosen.

2.2 Autologous double transposition
The original method has been described in detail previously [13]. Systemical heparinization is with 80 IU per kilogram bodyweight. The strategy of this rerouting procedure is to perform an end-to-side anastomosis between the left common carotid artery and the brachiocephalic trunk. Afterwards an end-to-side anastomosis is performed between the left subclavian artery and the already transposed left common carotid artery.

2.3 Total arch rerouting
The original method has also been described in detail previously [15]. Systemical heparinization is with 80 IU per kilogram bodyweight. An anastomosis between the proximal portion of an inversed bifurcated Dacron prosthesis (Braun Unigraft, Melsungen) and the ascending aorta is performed with reinforcement of Teflon felt strips with a 4-0 Prolene running suture (Ethicon, Inc, Somerville, NJ). Afterwards, an end-to-end anastomosis between the first branch of the prosthesis and the brachiocephalic trunk is performed. The next step is to perform an end-to-end anastomosis between the second branch of the prosthesis and the left subclavian artery. Finally, the left common carotid artery is reinserted into the branch to the left subclavian artery. Temporary atrial and ventricular pacemaker wires are affixed routinely.

2.4 Stent-graft systems used
Four different commercially available stent-graft systems were used. The Talent and after having been modified, the Valiant endovascular stent-graft (Medtronic, Santa Rosa, CA) were used in 10 patients. The Relay stent-graft (Bolton Medical, Sunrise, FA) was used in nine patients. The Excluder stent-graft (WL GORE, Flagstaff, AZ) was used in seven patients. The Endofit stent-graft (LeMaitre Vascular, Burlington, MA) was used in one patient. For all systems, the diameter of the stent-graft was calculated from the largest diameter of the proximal or distal neck and an oversizing factor of 10–20% was added.

2.5 Stent-graft placement
Stent-graft placement was performed during general anesthesia. In the majority of patients, a transfemoral approach was chosen. If the diameter of the external iliac artery was not large enough, the common iliac artery was used for arterial access. Stent-graft deployment was routinely performed under hypotonic conditions (60 mmHg systolic pressure). In patients with temporary pacemaker wires overpacing at 180 beats per minute was used to lower blood pressure. Intravascular ultrasound in determining landing zones as proposed by others was not applied in this series [18]. In our institution, no experience with regard to intravascular ultrasound is available and we are routinely using overlay projections to exactly define our landing zones. In patients with renal insufficiency we use a modified contrast agent being followed by extensive infusion of saline solution to prevent the kidneys from injury.

	3. Results

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Comment Appendix A References

 
3.1 Surgical procedure
All patients recovered uneventfully without any signs of transient or permanent neurologic injury after rerouting of the supraaortic branches. However, one patient died due to aneurysm rupture while waiting for stent-graft placement.

3.2 Stent-graft placement
Stent-graft placement was carried out metachronously after a mean time interval of 12 days. All endovascular procedures were completed uneventfully. Mean number of stent-grafts used was 2.3. We observed four early type Ia endoleaks. Two closed spontaneously during follow-up. The remaining are being observed as no feasibility of a proximal extension is available. One patient died the day prior to discharge due to myocardial infarction.

Mean hospital stay for both procedures—surgical and endovascular—was 17 days. Figs. 1 and 2 depict three-dimensional CT scans after double transposition and stent-graft placement in a patient with type B dissection and in a patient with multiple perforating ulcers. Fig. 3 depicts a three-dimensional CT scan after total arch rerouting and stent-graft insertion in a patient with an arch aneurysm.

View larger version (106K): [in this window] [in a new window]   Fig. 1. Double transposition and stent-graft in a patient with type B dissection.

View larger version (121K): [in this window] [in a new window]   Fig. 2. Double transposition and stent-graft in a patient with multiple perforating ulcers.

View larger version (103K): [in this window] [in a new window]   Fig. 3. Total arch rerouting and stent-graft in a patient with an aortic arch aneurysm.

	4. Comment

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Comment Appendix A References

 
Mid-term results of alternative treatment approaches in elderly patients with aortic arch pathologies are satisfying. Extended applications provide safe and effective treatment in patients at high risk for conventional repair.

According to better diagnostic tools, a variety of aortic pathologies are now being diagnosed. Aortic arch aneurysm treatment has been a domain of conventional surgery [7–9]. Recently, combined approaches have been developed thereby enabling treatment especially in patients not suitable for any kind of conventional repair with excellent short-term results [10–15]. However, mid-term and long-term results are still to be awaited.

Combined approaches have induced a change of mind in treatment algorithms of aortic arch pathologies. In our institution, the ratio of combined approaches and conventional arch replacements is three to one having been inverse some years ago. However, without doubt, these new treatment modalities are not without risk. It remains the decision of the individual treating physician if the natural course of the underlying disease or comorbidities exceed the risk of treatment or not. With regard to aortic arch aneurysms, the question is clear, as reliable data are available with regard to the natural course of the disease [5,6]. In patients with dissections, things are more complex. On one hand, with regard to prophylactic procedures as merely one out of four patients with an uncomplicated dissection will develop late aneurysm formation [19,20]. On the other hand in patients having already developed aneurysm formation on the basis of a chronic type B dissection as it remains to be shown if the self expandibility of the stent-graft will effectively readapt the chronic dissection membrane to the outer layers. In patients with perforating ulcers, the decision-making remains subjective as few data are available to predict the natural course of the disease [21]. Therefore clinical decision making, i.e. onset of symptoms of hoarseness and morphology irrespective of diameter will predict course and modality of treatment.

Furthermore, the decision making if patients should undergo conventional aortic arch replacement or if they should be offered combined minimally invasive approaches has to be discussed. In addition to clinical decision making, a risk stratification should be applied. EuroSCORE without doubt is not ideal to hundred percent in stratifying these patients with regard to their operative risk. However, to date, we do not have an ideal scoring system for these specific patients. Therefore, we have to apply current scoring systems in order to draw nearer to the answer. This was our rationale to apply the EuroSCORE. We do think that it has its merits, nevertheless we should aim to develop individual risk scores for patients with thoracic aortic pathologies.

With regard to the invasiveness, autologous double transposition has the lower impact as compared with total arch rerouting. Surgical access is gained via an upper hemi-sternotomy instead of full sternotomy in total arch rerouting. Furthermore, no alloplastic material has to be used, thereby avoiding the potential risk of graft infection [14]. Fortunately, graft infection of any kind has not been observed in this series. Other groups have proposed extraanatomical, extrathoracic rerouting procedures using carotideo-carotideal retropharyngeal alloplastic bypass grafting with consecutive overstenting of the left subclavian artery in distal arch aneurysms [22,23]. In our impression, access itself does not provide greater risk. Minimal invasiveness defines itself by avoiding cardiopulmonary bypass as well hypothermic circulatory arrest and not by avoiding hemi- or full sternotomy [24]. Furthermore, smaller alloplastic grafts may be more prone to sustain early or late thrombosis than any kind of autologous or orthotopic rerouting.

No transient or permanent neurologic injury could be observed in this series. However, one has to be self-critical as this might happen in future cases. Our potential explanations for this finding are the short cross-clamping times of the brain supplying vessels—for all anastomoses performed a median of 17 min was counted—and furthermore the absence of substantial atherosclerotic disease in the wall of the ascending aorta in total arch rerouting procedures. Without doubt, the risk of embolism is present in all these procedures and careful manipulation of central vessels as well as keeping cross-clamp times short in order to not exceeding the ischemic frame of cerebral tissue in mandatory for success.

Four commercially available endovascular stent-graft systems have been used. The first generation stent-grafts having been used at the very beginning of this series, had several technical drawbacks, mainly their rigid behavior. Therefore, passing the curve of the aortic arch was the main challenge. With newer devices these limitations have been solved. However, other questions have arisen. When deploying the graft within the curve, irrespective of being able to readjust or to immediately open, devices may make a move forward or backwards, thereby potentially threatening the orifice of either the brachiocephalic trunk or of the bifurcated graft. In our experience the Bolton device shows the best behavior with regard to that matter. Branched stent-grafts remain experimental for the moment and substantial improvements will have to be made until these devices will find their place in clinical routine [25]. The number of branches and the method of inserting the side branch into the target vessel remain the biggest challenges to date.

We observed four early type Ia endoleaks, two of them resolving spontaneously. The remaining are being observed as no feasibility of a proximal extension is available. Redo stent-graft placement was performed in one patient after 25 months due to a type III endoleak showing recurring shrinkage of the aneurysmal sac thereafter. Interestingly, no further endoleaks have been observed within the follow-up period thereby indicating that durability is favorable or in other words, if it works initially, long-term palliation is effectively provided by this combined approach.

4.1 Limitations of the study
This series represents a single center limited experience. We cannot provide a medical or surgical control group especially in patients with type B dissections and perforating ulcers. Upcoming clinical investigations and presumably larger multicenter databases will reconfirm the long-term benefit of this treatment strategy in these substantially comorbid patients.

Summarizing, mid-term results of alternative treatment approaches in elderly patients with aortic arch pathologies are satisfying. Extended applications provide safe and effective treatment in patients at high risk for conventional repair.

	Appendix A

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Comment Appendix A References

 
Conference discussion

Dr M. Turina (Zurich, Switzerland): Do you always repair the left subclavian artery? In our experience in Zurich it was necessary in less than one-third of the patients in Dr Lachat's series and two-thirds don’t need it.

Dr Czerny: Yes, we do. However, our main focus is not perfusion of the left upper extremity, but our main focus is the left vertebral artery due to posterior cerebral circulation. And actually it has been our policy from the very beginning in 1996 to reroute each subclavian artery.

Dr F. Beyersdorf (Frieberg, Germany): I would like to congratulate you on your very good results for this innovative approach for aortic arch aneurysm. In Freiburg we have done the same kind of treatment also with reversed Y grafting of the supra-aortic vessels in approximately eight cases. One of our problems is that the distal angle of the arch, which you have shown in the last slide, might lead to a misplacement of the distal part of the stent. So therefore my question is, what is your approach to overcome this?

My comment would be that you have shown in your slides, correctly, I think, that this is done for those patients in whom open repair or open replacement cannot be done. And especially for the open replacement of the arch, a number of great advances have been made over the years with antegrade perfusion bilaterally so that you can really do a very nice arch replacement in, let's say, younger patients.

And my third comment, Dr Weigang will give a talk shortly about the occlusion of the left subclavian artery, with which we, as Dr Turina just mentioned, also had some negative experience with covering the left subclavian artery and not looking to the cerebral circulation, but maybe we can discuss this in the next presentation.

Dr Czerny: With regard to the first question, I think this is a matter of choosing the right prosthesis for the right location of the thoracic aorta. And of course there are substantial differences between the provided prostheses on the market today, and it is also a matter of the length of the prosthesis, and so if you choose the right prosthesis for the right indication. And actually with the initial grafts we have been using in the arch area with the stiff short grafts, this was really tough to pass the curve, however, with newer devices and longer segments, this is getting better.

With regard to the second question, of course you are right, conventional arch replacement nowadays due to antegrade selective cerebral perfusion and moderate hypothermia has, of course, better results than 10 years ago. However, as you said, this approach is thought mainly for patients not suitable for any kind of conventional repair.

Dr B. Zipfel (Berlin, Germany): Did you experience any cerebrovascular complications during revascularization? Unfortunately, we had one serious complication with a soft atheroma in the common carotid.

Dr Czerny: I know what you mean. Actually we didn’t experience it, but from time to time you have cases you are really lucky that you get out without any cerebral complication, because it is completely right, sometimes there is substantial atheromatous debris at the proximal portion of these vessels, and also from time to time you may have a length problem. And that is what I wanted to stress also, this supraaortic, or this extrathoracic mobilization of the vessels in order to enable tension-free accomplishment, and this also helps you in these heavily diseased proximal vessels.

Dr M. Turina (Zurich, Switzerland): One last question. The problem of embolization from the ascending aorta is, of course, enormous, and I am surprised that you got such a low incidence of embolization. Do you have any special measures? Do you perform epiaortic scanning before doing that trying to find a spot, because sometimes the aorta is terrible in degenerative aneurysms.

Dr Czerny: We completely rely on the preoperative CT scan. In the patient we had this temporary neurological deficit, he had a substantially heavily diseased ascending aorta. But I think this is much more a problem in patients with ulcers of the arch than it is in aneurysms, because in these aneurysm patients we hardly ever see some substantial derangements of the ascending aorta, rather in patients with perforating ulcers of the arch.

	Footnotes

 
^\#9734; Presented at the joint 20th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 14th Annual Meeting of the European Society of Thoracic Surgeons, Stockholm, Sweden, September 10–13, 2006.

	References

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Martin Czerny Daniel Zimpfer Martin Grabenwoger Ernst Wolner Michael Grimm Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Czerny, M. Articles by Grimm, M. Search for Related Content PubMed PubMed Citation Articles by Czerny, M. Articles by Grimm, M. Related Collections Great vessels