Hybrid Repair of Aortic Arch Aneurysms: A Totally Extrathoracic Approach with Branched Endografts in Two Patients

Marcelo Ferreira; Timothy Chuter; David Hartley; Luiz Lanziotti; Giafar Abuhadba; Marcelo Monteiro; Luis Capotorto

Disclosures

Vascular. 2007;15(2):79-83. 

In This Article

Case Reports

Case 1

A 56-year-old man with a medical history of hypertension, congestive heart failure, heavy smoking, alcoholism, and a small abdominal aortic aneurysm developed a 10 cm sacular aneurysm arising from the inferior aspect of the aortic arch, opposite the origin of all of the great vessels. Traditional open surgery, with complete arch replacement under hypothermic extracorporeal circulation, was considered extremely high risk in view of the patient's cardiopulmonary comorbidities. After approval by the hospital ethics committee, we offered him an extrathoracic approach, based on a previously reported case of a complete endovascular arch debranching with a modular branched endograft.[11]

The custom-made endografts used in both cases have a similar modular design, with a proximal bifurcated graft with one branch opening into the innominate artery (fig 1) and the other opening into another aortic endograft that terminates in the descending thoracic aorta below the aneurysm (Zenith TX2 thoracic graft, Cook Incorporated, Brisbane, Australia). The proximal graft is inserted through a conduit anastomosed to the common carotid or innominate artery, and the distal component is inserted through a standard femoral approach. In association with the endograft, we performed a carotid-carotid retropharyngeal bypass and a left subclavian to carotid transposition (fig 2 and fig 3).

Figure 1.

Modular stent graft to the arch, proximal component. A, In vitro testing. B, Computed tomographic scan of the complete graft.

Figure 2.

A and B, Pre- and postoperative three-dimensional computed tomographic (CT) scans of the aneurysm; C and D, pre- and postoperative CT views of the aneurysm; E and F, intraoperative angiogram and postoperative CT scan depicting the new path to the cerebral blood flow.

Figure 3.

A and B, Preoperative computed tomographic (CT) scans of the aneurysm; C and D, intraoperative angiograms depicting the aneurysm and the subclavian transposition and carotid-carotid bypass; E to H, postoperative CT views of the treated aneurysm and the grafts.

The procedure was conducted under general anesthesia with adjunct cerebrospinal fluid drainage and monitoring. A pacemaker was introduced via the left femoral vein, in case subsequent adenosine-induced cardiac arrest failed to revert to a spontaneous cardiac rhythm.

The surgery was performed in two stages. The first consisted of left subclavian to carotid transposition via a supraclavicular approach, carotid-carotid retropharyngeal bypass with an 8 mm ringed polytetrafluoroethylene graft, and the anastomosis of a 10 mm Dacron conduit to the innominate artery.

The second stage consisted of bifurcated stent graft insertion through the conduit and a TX2 insertion through the femoral artery. During this stage, the cerebral circulation was initially maintained by the left common carotid since the innominate artery was temporarily occluded by the endograft introducer system. The introducer was withdrawn prior to insertion of the TX2 to allow inflow through the long line of the bifurcated stent graft to the innominate artery and through the carotid-carotid bypass to the left carotid and left subclavian arteries.

Following transfemoral catheterization of the short limb of the bifurcated graft, the TX2 graft was inserted in the usual fashion over a stiff guidewire. Both were deployed under adenosine-induced cardiac arrest (16 mg, inducing 20 seconds of cardiac arrest). The proximal right subclavian artery was ligated after the endograft was placed. Finally, the left common carotid and subclavian arteries were occluded proximally to prevent a type 2 endoleak.

The completion angiogram showed flow to all four brachiocephalic arteries and no endoleak (see fig 2).

The patient's discharge was delayed 60 days by severe pulmonary complications worsened by symptoms of alcohol withdrawal. The patient remains well over a year later, and computed tomographic (CT) angiography 12 months after the procedure demonstrated aneurysm exclusion with unobstructed circulation through all of the grafts (see fig 2).

Case 2

A 54-year-old woman with refractory hypertension developed an 8 cm saccular aortic arch aneurysm, in a position similar to that described in case 1. The patient refused open chest surgery, and based on the previously performed cases, we offered the patient a similar hybrid approach, approved by the ethics committee (see fig 3). The endograft was custom-made for the patient.

In this case, we performed a bilateral subclavian to carotid transposition 1 week before the main procedure. Both stent grafts were inserted through conduits, one to the innominate artery, as before, and the other through the right common iliac artery. Otherwise, the procedure followed the same steps as for case 1.

The patient had an uneventful recovery and was discharged 5 days later, with antiplatelet therapy. After 6 months, the patient remained clinically well, and CT angiography showed aneurysm exclusion and good flow through all of the grafts.

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