Hybrid Repair of an Aortic Arch Aneurysm Using Double Parallel Grafts Perfused by Retrograde Flow in Endovascular Repair Combined With Left Subclavian Artery Surgical Bypass

Modification in aortic arch replacement surgery

Objective

We modified the conventional aortic arch replacement procedure to avoid circulation arrest and a prolonged extracorporeal circulation time, especially in cases of acute aortic dissection. We herein present our experience with a modified branch-first approach to acute aortic dissection, with anastomosis of the supra aortic vessels prior to commencing cardiopulmonary bypass.

Methods

Since 2012, 41 patients (aortic dissection, 36; arch aneurysm, 5) have undergone the modified procedure. Procedurally, the implanted graft was used as a landing zone for second-stage endovascular stent-graft deployment intended to manage the residual descending dissection. Antegrade and retrograde systemic perfusion was instituted during cardioplegic arrest. The brain was actively perfused via the graft throughout the procedure.

Results

Arch replacement surgery could generally be completed within approximately 4 h. During a 2-year period of aortic dissection or arch aneurysm treatment, only four anastomoses were required during the first stage of operation: two in the aorta, and one each in the innominate and left common carotid arteries. No patient died of surgical causes, and no stent grafts were deployed into the false lumen, a characteristic of procedures using traditionally antegrade deployment.

Conclusion

We recommend that our procedure for acute aortic dissection be performed in two stages (graft replacement first and stent graft deployment second), particularly for patients underwent preoperative hypotesion. If malperfusion syndrome still exists after graft replacement, stent graft should be deployed in one stage. The arch aneurysm can be treated in one stage because there is no concern about false lumen deployment.

Electronic supplementary material

The online version of this article (10.1186/s13019-017-0689-y) contains supplementary material, which is available to authorized users.

Sandwich Technique for Endovascular Repair of Acute Type A Aortic Dissection

Overview: To describe a new endovascular procedure for acute type A aortic dissection (TAAD) repair. Methods: Between 2013 and 2016, 12 patients (average age 54±9.6 years; 10 men) with acute TAAD (mean EURO score 11.4%±3.2%, range 5–17) and unfit for surgery underwent thoracic endovascular aortic repair (TEVAR) with 2 periscope grafts to preserve blood supply to supra-aortic branches plus bypass grafting as needed. If the ascending aorta was dilated to >40 mm, sternotomy was performed to wrap the ascending aorta and reduce its diameter to accommodate the aortic stent-grafts. Results: All patients were successfully treated. Seven patients required bypass grafting, and most of the patients had periscope grafts to the innominate/right common carotid artery and left common carotid artery; only 3 patients had the left subclavian artery preserved. All patients exhibited good hemodynamics and normal pressures after the procedure. The mean procedure time and blood loss were 4.5±1.0 hours and 217±111.5 mL, respectively. Two patients treated emergently died shortly after surgery from multiorgan failure. The average follow-up duration was 17±14.5 months (range 2–42) in the 10 survivors. The remaining patients recovered and none experienced stent-graft thrombosis, stroke, or peripheral artery embolism during follow-up. Conclusion: A procedure that combines sandwich/periscope grafting with TEVAR, wrapping of the aorta, and supra-arch bypass grafting can be used to treat patients with acute TAAD.

A Modified and Less Invasive Procedure in Aortic Arch Replacement

Circulation arrest is widely used during total aortic arch replacement. However, the conventional procedures have high morbidity and mortality. We modified the hybrid procedure by optimizing the sequence of anastomosis between the graft and aorta. As a result, the time of extracorporeal circulation was obviously shortened, and cardiac arrest was needed only during the two anastomoses of the aorta with aorta graft main body. In addition, both circulation arrest and deep hypothermia were avoided. Leakage was also prevented by creating a lengthened sealing zone for stent graft deployment.