Hybrid arch repair including supra-aortic debranching on the descending aorta

Hybrid Repair with Reversed Sequence Supra-aortic Debranching in Ruptured Arch Aneurysm

Aortic arch pathology in a high-risk patient in whom the resternotomy approach is unfeasible due to treated mediastinitis after ascending aortic replacement presents a unique challenge for hybrid arch repair (HAR) because of the need for supra-aortic debranching from unusual inflow sites other than the ascending aorta. This report describes a "reversed sequence" extra-anatomical supra-aortic debranching procedure as a salvage technique performed to enable HAR. An 83-year-old woman with a history of ascending aortic replacement for type A aortic dissection, mediastinitis complicated by sternal osteomyelitis, and a chest wall reconstructed with a rectus abdominis myocutaneous flap presented with chest pain because of a contained dissecting arch aneurysm rupture. The patient underwent supra-aortic debranching from the bilateral common femoral arteries and thoracic endovascular aortic repair to the ascending aorta under cerebral near-infrared spectroscopy (NIRS) monitoring. Completion imaging by angiography demonstrated successful exclusion of the ruptured aneurysm. The regional cerebral oxygen saturation level, monitored by NIRS, did not change markedly during surgery. The patient was neurologically intact with adequate cerebral blood flow assessed postoperatively by ¹²³ I-IMP single photon emission computed tomography. Total debranching of the supra-aortic vessels from the common femoral artery for inflow is feasible and provides adequate cerebral perfusion. This procedure may offer an alternative treatment option in patients with complex conditions involving aortic arch pathology.

Thoracic Endovascular Aortic Repair Including Total Debranching on Femoral Artery for Arch Rupture

A 94-year-old woman with rupture of a thoracic aortic aneurysm (rTAA) was referred to us. She previously underwent thoracic endovascular aortic repair and was considered to be at high risk for a conventional open operation. Therefore an endovascular procedure was planned. The proximal landing zone needed to be placed at the ascending aorta to seal a type 1a endoleak. A hybrid operation consisting of supraaortic total debranching on the common femoral artery and endovascular repair was performed. All debranched bypasses were patent and the aneurysm was excluded. The patient regained sufficient ambulatory strength and showed no symptoms of syncope.

A novel technique of total debranching TEVAR with inflow from the descending aorta

An 82-year-old male with TAA was considered high risk for conventional surgery because of previous CABG. Therefore, a hybrid repair was performed. First, the arch vessels were debranched extra-anatomical bypass. Second, left thoracotomy was performed. The proximal side of a bifurcated graft was anastomosed to the descending aorta. To arch vessels' debranch graft, two bifurcated graft distal limbs were anastomosed with a 10-mm distance. Two stentgrafts were deployed from the ascending to descending aorta. Postoperative CT did not reveal any endoleak, and all debranch grafts were patent.

Hybrid Repair of Ruptured Arch Aneurysm Without Sternotomy Through an Unusual Extraanatomic Bypass

A 42-year-old man experienced a complex aortic arch aneurysm rupture. He had previously undergone an operation for type A dissection and had extremely poor cardiac performance as well as deep sternal infection after the first procedure. The conventional open repair was considered to be a high risk for this patient. We therefore performed an alternative hybrid aortic procedure. The supraarch vessels were perfused through an extraanatomic bypass from an unusual and remote route, namely, the abdominal aorta. Then, stent grafts were implanted in the previously replaced aortic prostheses to exclude the aortic aneurysm. The patient recovered uneventfully with no neurologic adverse events.

Hybrid Procedure with Debranching from the Descending Aorta for Aortic Arch Aneurysm after Previous Open Repair

Aortic arch aneurysms can be treated with hybrid procedures by endovascular exclusion and prior debranching of supra-aortic arteries. We report on a case of symptomatic arch aneurysm following previous supracoronary ascending aorta and hemiarch replacement with a very short proximal landing zone. A successful reconstruction was performed by retrograde revascularization of supra-aortic vessels from the descending aorta and subsequent endovascular repair deploying a proximal stent graft directly above the sinotubular junction with good results in the 4-year follow-up. Retrograde supra-aortic debranching may constitute a suitable approach for hybrid endovascular repair of aneurysms of the aortic arch and the ascending aorta in selected cases.

A Simplified Arch Debranching Technique for Hybrid Repair of Complicated Type B Aortic Dissection

Convenient procedures and fewer postoperative adverse events of an arch debranching technique are important factors that need to be considered for assured outcomes of hybrid repair. In this report we describe our hybrid repair with a simplified arch debranching technique. It was used for patients with complicated type B aortic dissection who had undergone previous operations for type A aortic dissection. With this technique, the treatment for complicated type B aortic dissection becomes easier and less invasive, which is especially advantageous for patients with high surgical risk for conventional open repair.

Hybrid thoracic endovascular aortic repair of ascending aortic pseudoaneurysm

We report the successful thoracic endovascular aortic repair of an ascending aortic pseudoaneurysm. Because the risk of resternotomy after conventional surgery was very high, endovascular repair with extra-anatomic reconstruction of the supra-aortic vessels was performed using the femoral artery as the donor artery. Complete exclusion of the pseudoaneurysm was achieved, with no postoperative complications or neurologic sequelae.

Cerebral blood flow after hybrid distal hemiarch repair

OBJECTIVES

Aortic arch disease can be treated with hybrid repair (extra-anatomic bypass plus placement of aortic endoprostheses), but there is controversy about whether a bypass from one relatively small vessel will provide adequate blood flow to the entire brachiocephalic system. We, therefore, compared flow volumes before and after hybrid repair.

METHODS

We reviewed the records of 16 patients who underwent a hybrid distal hemiarch repair between October 2010 and May 2012. The procedure consisted of debranching of the left subclavian and left common carotid arteries, creation of a bypass to these vessels from the right subclavian artery by using a T-shaped synthetic graft, and placement of a stent graft. Preoperative and postoperative measurements of blood flow volume in the carotid and vertebral arteries and of regional cerebral blood flow were performed in ~70% of the patients.

RESULTS

Perioperative complications were one new-onset, fatal acute aortic dissection and two minor strokes. No major endoleaks occurred. Postoperatively, mean flow volumes in the right and left common carotid arteries, right and left internal carotid arteries, and right and left vertebral arteries were 423 and 393, 271 and 189, and 87 and 80 ml/min, respectively. Regional cerebral blood flow in the territories of the anterior, middle and posterior cerebral arteries was not significantly different from preoperative levels, as assessed both with and without administration of acetazolamide.

CONCLUSIONS

Hybrid distal hemiarch repair preserved regional cerebral blood flow and vasoreactivity, although flow in the common and internal carotid arteries was right-side dominant postoperatively.

Thoracic endovascular aortic repair in patients with prior open aortic surgery

OBJECTIVE

To review our experience of thoracic endovascular aortic repair (TEVAR) in patients with prior open aortic repair (OAR).

MATERIALS AND METHODS

Stent-grafts were deployed in the arch, descending thoracic and thoracoabdominal aortae of 39, 13 and 5 patients, respectively, and in a deteriorated extra-anatomical prosthesis in one. The access route was the femoral artery in 10 of 23 patients with, and in 30 of 35 patients without a prior abdominal prosthesis. Prior prostheses and elephant trunks comprised 57 of 116 landing zones and 23 proximal landing zones, respectively.

RESULTS

Three patients died before discharge. Type II endoleaks developed in six patients, and Types I and III developed in one patient each. Type I endoleaks were not found at landing zones comprising prosthetic grafts. The overall actuarial three-year survival rate including early mortality was 86.5%.

CONCLUSION

The clinical outcomes of TEVAR were excellent, even in patients with prior OAR. Prosthetic grafts, including elephant trunks, provided good landing zones for TEVAR. Prostheses with larger-caliber designs are recommended for iliac artery reconstruction in future TEVAR.