Rapid Aortic Arch Debranching Using the Gore Hybrid Vascular Graft

Aortic arch debranching in hybrid thoracic aortic replacement

OBJECTIVE

To analyze the outcomes of aortic arch debranching in hybrid thoracic aortic replacement.

MATERIAL AND METHODS

There were 107 patients who underwent hybrid thoracic aortic repair with debranching of supra-aortic vessels between 2015 and 2021. Patients underwent total and partial debranching (subtotal debranching and subclavian-carotid anastomosis/bypass). Debranching was performed in patients with type 3 dissection, type B aneurysms, post-traumatic aortic isthmus and arch aneurysms, thoracoabdominal aneurysms type A and DeBakey type 1 dissections.

RESULTS

One patient (0.9%) died from thoracic aorta rupture after retrograde dissection. There was a moderate decrease of blood flow velocity through the left vertebral artery after subtotal debranching without severe hemodynamic disorders. Despite mild surgical trauma, subtotal and especially total debranching are characterized by higher risk of thrombosis of branches with potential fatal outcomes. In young patients requiring subtotal aortic arch debranching, open reconstruction or repair with fenestrated stents is preferred. We recommend a Bavaria type II hybrid procedure for patients with high surgical risk. In our opinion, more physiological hybrid interventions with anatomical arrangement of supra-aortic vessels such as Elephant Trunk and Frozen Elephant Trunk procedures are preferred.

Clinical Experience with the Gore Hybrid Vascular Graft in Complex Revascularizations Demonstrates Safety and Efficacy

BACKGROUND

Arterial revascularizations can present significant challenges when vessels are disadvantaged and advances in technology present the surgeon with innovative opportunities. A number of studies have used the GORE® Hybrid Vascular Graft (GHVG), and we have been using this device in arterial revascularizations since it came to market. The aim of this study is therefore to present a large single-center experience using the GHVG. This series presents patients with complex revascularizations in multiple vascular beds.

METHODS

We retrospectively analyzed a single-center series of 43 patients who received a total of 56 GHVGs in complex revascularization procedures at Houston Methodist Hospital from March 2012 to April 2017. We excluded 5 patients (7 grafts in total) because of loss of follow-up. An additional 8 patients were excluded from the analysis (11 grafts in total) secondary to mortalities unrelated to their grafts (7 patients died during index hospitalization and 1 patient died shortly after discharge).

RESULTS

Our results demonstrated an 18-month primary patency, assisted primary patency, and secondary patency of 82, 86, and 96%, respectively. These complex revascularizations included a total of 56 devices placed. GHVGs were placed in the external iliac artery (27/56), renal artery (12/56), common femoral artery (6/56), superficial femoral artery (4/56), common iliac artery (3/56), grafts (3/56), profunda femoris artery (1/56), and the superior mesenteric artery (1/56). Early mortality in patients (7/8) was because of the nature of their disease and not related to the surgical intervention.

CONCLUSIONS

The GHVG has the ability to create a sutureless anastomosis in a disadvantaged vessel or to promote a potentially better outcome by either avoiding prolonged ischemia to visceral branches or avoiding extensive abdominal or retroperitoneal exposure in an iliofemoral bypass. These results demonstrate the value of the GHVG in complex revascularizations not amenable to traditional open surgical bypass.

LEVEL OF EVIDENCE

IV.

Management of the difficult left subclavian artery during aortic arch repair

Management of the left subclavian artery (SCA) during aortic arch surgery is associated with several challenges, including preserving distal perfusion, achieving hemostasis and preventing posterior circulation stroke and spinal cord injury. The most common challenge remains its deep position in the chest, often exacerbated by posterior and apical displacement from an arch aneurysm. We discuss several management options consisting of pre-, intra- and post-operative strategies and their respective advantages, disadvantages and clinical outcomes. A clinical algorithm is proposed to help guide decision-making in managing the difficult left SCA during aortic arch repair.

Over-the-balloon placement of the Gore Hybrid Vascular Graft in challenging clinical conditions

This report describes a useful technique for deployment of the Gore Hybrid Vascular Graft (W. L. Gore and Associates, Flagstaff, Ariz) in difficult clinical situations that create challenges in obtaining vascular control before introducing the nitinol-reinforced section of the graft. In both arterial and venous applications, introducing the Gore Hybrid Vascular Graft over a balloon allows concurrent vascular control by inflation of the balloon and easier introduction of the device into the recipient vessel by creating a smoother transition between the leading edge of the graft and the guidewire. Examples of both arterial and venous applications of this novel technique are presented.

Clampless and Sutureless Hybrid Technique for Aortic Arch Debranching on a Porcelain Aorta

An innovative hybrid approach to the supraaortic vessels in a porcelain aorta and severe fibrotic tissue reaction at the neck is described. The technique is demonstrated in an 80-year-old woman with previous several carotid operations but still experiencing recurrent transient ischemic attacks. Clinical success was achieved at midterm follow-up, demonstrating the efficacy of hybrid treatment for this high-risk patient. Novel prosthetic vascular grafts that can be applied without cross-clamping may also provide a solution to approaching a porcelain aorta and difficult anatomies.

Application of a Hybrid Vascular Graft for Rapid Endoluminal Branch Anastomoses During Open Aortic Reconstruction

The treatment of thoracoabdominal aneurysms and juxtarenal aortic aneurysms remains technically challenging, with outcomes primarily dictated by aortic cross-clamp and end-organ ischemia during branch reconstruction. This has remained a challenge for the surgeon regardless of an elective setting or an emergent operation. Here we describe the application of a novel hybrid graft technique for aortic branch reconstruction using rapid, endoluminal anastomoses during open aortic reconstruction.

Open repair of an aortic aneurysm in a patient with Loeys-Dietz syndrome using Gore hybrid vascular branch grafts

A 44-year-old woman with Loeys-Dietz syndrome (transforming growth factor-β [TGFBR2] gene mutation) presented with a retrograde type B dissection. She developed rapid expansion of the thoracoabdominal aortic false lumen aneurysm. The patient was successfully treated with open thoracoabdominal repair using Gore Hybrid Vascular Grafts (W. L. Gore and Assoc, Flagstaff, Ariz) for revascularization of the celiac trunk, the superior mesenteric artery, and both renal arteries. Follow-up imaging documented patency for all visceral branches. The described off-label use for sutureless revascularization might be a fast, simple, and reliable solution for revascularization during open thoracoabdominal repair. Furthermore, anastomotic aneurysm in patients with connective tissue disease might be prevented by sutureless anastomosis.

Thoracoabdominal aortic aneurysm repair: current endovascular perspectives

Thoracoabdominal aneurysms account for roughly 3% of identified aneurysms annually in the United States. Advancements in endovascular techniques and devices have broadened their application to these complex surgical problems. This paper will focus on the current state of endovascular thoracoabdominal aneurysm repair, including specific considerations in patient selection, operative planning, and perioperative complications. Both total endovascular and hybrid options will be considered.