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

Accepted Manuscript Hybrid Procedure With Debranching From the Descending Aorta for aortic Arch Aneurysm After Previous Open Repair Juergen Zanow, Martin Breuer, Eric Lopatta, Christoph Schelenz, Utz Settmacher PII:

S0890-5096(16)30671-9

DOI:

10.1016/j.avsg.2016.05.131

Reference:

AVSG 2981

To appear in:

Annals of Vascular Surgery

Received Date: 18 March 2016 Accepted Date: 26 May 2016

Please cite this article as: Zanow J, Breuer M, Lopatta E, Schelenz C, Settmacher U, Hybrid Procedure With Debranching From the Descending Aorta for aortic Arch Aneurysm After Previous Open Repair, Annals of Vascular Surgery (2016), doi: 10.1016/j.avsg.2016.05.131. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT Title. Hybrid procedure with debranching from the descending aorta for aortic arch aneurysm after previous open repair

Author names and affiliations.

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Juergen Zanow1, Martin Breuer2, Eric Lopatta3, Christoph Schelenz4, Utz Settmacher1

Department of General, Visceral and Vascular Surgery, 2 Department of Heart and Thoracic Surgery, 3 Institute of Diagnostic and Interventional Radiology, 4 Department of Anaesthesiology, Jena University Hospital, Jena, Germany Corresponding author.

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Juergen Zanow [email protected] tel.: +4936419322601 fax: +4936419322603

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Jena University Hospital Department of General, Visceral and Vascular Surgery Erlanger Allee 101 07740 Jena Germany

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

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KEY WORDS aneurysm – thoracic aorta- aortic arch – endovascular therapy – TEVAR – supraaortic debranching

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ACCEPTED MANUSCRIPT Introduction

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Aortic arch replacement necessitates sternotomy, a cardiopulmonary bypass and

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deep hypothermia. It is associated with significant morbidity and mortality risks that

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correlate with increasing patient age. 1, 2 The feasibility of open reconstruction may

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be limited by several factors including complications resulting from prior cardiac

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surgery, comorbidity and patient’s refusal of the open replacement. Hybrid

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procedures comprising revascularization of arch vessels and a subsequent thoracic

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endovascular aneurysm repair (TEVAR) are less invasive and have yielded

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encouraging early and mid-term results.1-6 However, no reliable long-term data are

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available that would ascertain the long-term durability of reconstruction. Cao et al.

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concluded that this hybrid approach presented a persistent high risk of perioperative

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mortality, especially if repair involved the ascending aorta.7

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For successful stent graft placement and sealing, a sufficient proximal landing zone

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in the aorta of at least 20 mm is essential. 5, 8 A reconstruction of the entire aortic

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arch requires a complete debranching of aortic arch arteries and is usually performed

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by bi- or trifurcated Dacron graft bypass from the ascending aorta to the supraaortic

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arteries via a sternotomy in order to ensure a sufficiently long proximal landing zone

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for TEVAR. Here, we describe a case of a hybrid TEVAR of an aortic arch

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pseudoaneurysm in a high-risk patient who was not a candidate for conventional

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debranching and TEVAR because of an unfavourable aortic morphology and a

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categorical refusal of re-sternotomy.

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Case report

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The 78-year-old female patient underwent an acute surgical procedure in 2008 for

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rupture of the aortic arch. The rupture was probably caused by a chronic retrograde 3

ACCEPTED MANUSCRIPT Type A aortic dissection beginning at the inner curvature opposite the origin of the

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left subclavian artery. A supracoronary ascending aorta and hemi-arch replacement

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was performed including reattachment of supraaortic vessels as an island to the

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graft. A revision for mediastinal hematoma was necessary at postoperative days 2

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and 39. Thereafter, the course was uneventful and the patient recovered well.

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In 2010, a progredient aneurysm of the reconstructed aortic arch with a maximal

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diameter of 75 mm was detected (Fig 1) after the patient had reported suffering

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persistent painful pulsating sensations for a few weeks. Since no signs of infection

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were observed, redo surgery was indicated. However, both the patient and the

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cardiac surgeons refused the open aortic arch repair procedure. Hence, the patient

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was advised to consider an endovascular approach.

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The problem of endovascular hybrid repair of the aortic arch became apparent in CT

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scan reconstruction (Fig 2). The previously implanted tube graft was very short, the

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distance between the coronory ostia and the aneurysmatic arch encompassing only

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about 22 mm. Besides refusal and risks of resternotomy, this limitation precluded the

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possibility of performing an anastomosis for typical debranching and for providing a

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sufficiently proximal endograft landing zone. On the other hand, since the descending

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aorta was not dilated or calcified, we decided to implant extra-anatomic bypasses to

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the supraaortic vessels from the descending aorta and to place the aortic stent graft

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from the proximal descending aorta to the ascending thoracic aorta ending right

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above the sinotubular junction.

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Under general anesthesia, the common carotid and subclavian arteries were

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exposed through a bilateral cervical approach. The descending aorta was exposed

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via a left postero-lateral mini-thoracotomy. To avoid graft compression, a segment of

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the first rib was resected through a short incision at the left supraclavicular fossa.

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After creation of a tunnel, one leg of a bifurcated aortic Dacron graft (14-7-7 mm) was 4

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arteries through a retropharyngeal tunnel. Following systemic heparin administration

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the descending aorta was clamped tangentially and a side-to-end anastomosis with

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the bifurcation graft was established. The distal ends of the graft legs were

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anastomosed in an end-to-end manner with both common carotid arteries using a

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temporary intraluminal shunt. Following central ligation both subclavian arteries were

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then revascularized.

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After completion of debranching, the TEVAR procedure was performed through a

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transfemoral approach. A pigtail catheter and a super stiff Backup-Meier wire with a

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pre-bent tip were placed into the ascending aorta and the left ventricle, respectively.

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A distal aortic stent graft (30 mm diameter; 150mm in length) was placed and an

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overlapping second stent graft (34 mm diameter; 150 mm length; Closed Web

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Valiant; Medtronic Vascular, Santa Rosa, Calif) was deployed right above the

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sinotubular junction. As the distal stent graft was placed under hypotonia, the central

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stent graft was deployed during transient cardiac arrest induced by rapid right

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ventricular pacing under ventilator breath-hold. To ascertain accurate placement, the

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deployment was monitored by aortography and echocardiography.

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Despite a prolonged initial artificial ventilation for pulmonary insufficiency for 48

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hours, the patient recovered well and could be discharged 12 days after the

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procedure. No neurological deficits were observed and both the CT scan and

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echocardiography demonstrated normal postoperative findings.

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Five years later, at age 83, the patient is still well. A recent CT scan verified the

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correct graft position, patent bypasses to supra-aortic vessels, and a completely

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thrombosed aneurysm, which shrunk from 75 to 59 mm (Fig. 3)

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About 20% of patients need a reoperation for different indications after previous

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acute type A aortic dissection repair.9 In particular, the repair of false aneurysms

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represents a very challenging procedure and has a mortality rate of 14%.9, 10

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Combining open surgical debranching of supra-aortic arteries and TEVAR, hybrid

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arch repair has been introduced as an alternative procedure, especially in high-risk

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patients.

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TEVAR requires a minimum of at least 20 mm of suitable aorta in zone 0 (ascending

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aorta-innominate origin) for stent graft landing after typical supra-aortic debranching

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from the ascending aorta. An ascending aortic replacement combined with total arch

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debranching can be conducted to create an appropriate landing zone, but requires a

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sternotomy and cardiopulmonary bypass.

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Total arch rerouting from the descending aorta as an alternative approach has been

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considered and different techniques for arch vessels reconstruction have been

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discussed in the literature. 1, 11, 12 However, to date, only few cases have been

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reported in which the descending aorta was actually used for hybrid arch repair.11, 13-

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the procedures reported in the literature.

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In the case presented herein, re-sternotomy and cardiopulmonary bypass for open

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arch reconstruction repair as well as extension of ascending aorta replacement for an

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optimal landing zone and debranching were declined by both the patient and the

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cardiac surgeons. The descending aorta was suitable as a distal landing zone and for

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side-biting clamping and also opened the possibility of retrograde total arch vessel

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debranching. Total arch debranching from the descending aorta appears to be more

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feasible and safe than debranching from the femoral or iliac arteries.17, 18

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Even though the length of the proximal landing zone was critically short and needed

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Of note, the technique for supraclavicular arterial reconstruction differed in each of

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to be fully utilized, an accurate deployment of the stent graft right above the

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sinotubular junction could be accomplished safely by transient cardiac arrest. This

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procedure resulted in a good long-term outcome.

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In patients at high surgical risk for open repair or conventional complete aortic arch

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debranching (sternal infection, multiple sternotomies, large false aneurysms after

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previous repair), a debranching from the descending aorta appears as a viable

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approach in selected cases.

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Figure captions

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Fig. 1

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Preoperative 3-dimensional CT scan reconstruction.

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Preoperative 2-dimensional CT scan orthogonal to the aortic center line.

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Postoperative 3-dimensional CT scan reconstruction five years after TEVAR.

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Fig. 4

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Preoperative CT scan of arch aneurysma

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CT scan five years after TEVAR

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