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Hybrid Repair of an Aortic Arch Aneurysm Rupture in a Redo Sternotomy
CLINICAL SPOTLIGHT
Heart, Lung and Circulation (2014) 23, e258–e260 1443-9506/04/$36.00 http://dx.doi.org/10.1016/j.hlc.2014.07.068
Hybrid Repair of an Aortic Arch Aneurysm Rupture in a Redo Sternotomy Tam Nguyen *, Matthew Claydon, Silvana Marasco Vascular Surgery Department, Alfred Hospital, Commercial Road, Prahran, Vic, 3181, Australia Received 25 January 2013; received in revised form 9 July 2014; accepted 23 July 2014; online published-ahead-of-print 15 August 2014
Purpose
To report a case of operative intervention for an aortic arch aneurysm rupture via a hybrid approach.
Methods and Results
Ten years after successful open repair of an acute type A aortic dissection a male presented with a rupture of his distal aortic arch aneurysm. A hybrid procedure was carried out which involved debranching of the innominate and left common carotid arteries and stent-graft deployment landing proximally into the ascending aorta and distally into the descending thoracic aorta.
Conclusions
Ruptured aortic arch aneurysms present a challenging and complex surgical dilemma. Open repair carries high mortality and pure endovascular repair is unfeasible; hence a hybrid repair presents an attractive solution.
Keywords
Aortic arch Aneurysm Rupture Hybrid repair
Introduction Conventional open repair of thoracic aortic aneurysms involving the aortic arch is associated with significant morbidity and mortality. Hybrid procedures have been developed to provide surgical options for elective patients previously at significantly high risk for conventional open repair and its application in the emergency treatment of a ruptured aortic arch aneurysm holds much promise [1,3]. We present a case report of a patient that presented to our hospital with a ruptured aortic arch aneurysm and was subsequently treated with a hybrid procedure through a redo sternotomy.
Case report A 70 year-old man presented to our institution with severe interscapular pain and hypotension. He had a history of an aortic valve and aortic dissection repair and ascending aortic graft replacement for an acute type A dissection performed 10 years prior. He had been lost to follow-up. An urgent CT
angiogram was performed which showed a large left-sided haemothorax contiguous with an arch aneurysm and persistent dissection in the proximal descending thoracic aorta extending to the iliac vessels. The diagnosis of a distal rupture of an aortic arch aneurysm was made (Figure 1). Extensive discussion occurred between the cardiothoracic and vascular teams to explore the various treatment options. Open thoracotomy and circulatory arrest followed by arch and descending thoracic aortic replacement was thought likely to result in certain death. A complete endovascular option would not be available in an emergency setting as a custom-made device would need to be designed and manufactured. A hybrid procedure was decided upon with a debranching procedure from the previous ascending aortic graft to the innominate and left common carotid artery planned and proximal ligation of the innominate, left common carotid artery and left subclavian artery. The ligation of left subclavian artery was planned for after graft deployment allowing its use for imaging access if this proved necessary. A conduit off the debranching graft would allow a stent graft to be deployed antegrade from the ascending aorta (landing ‘‘zone
*Corresponding author at: Vascular Surgery Department, Alfred Hospital, Commercial Road, Prahran, Vic, 3181, Australia., Email: [email protected] © 2014 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier Inc. All rights reserved.
e259
Hybrid Repair of an Aortic Arch
Figure 2 CT angiogram post hybrid repair.
Figure 1 CT angiogram showing ruptured aortic arch aneurysm.
0’’) to the descending aorta. A range of TX2 (Cook Inc., Bloomington, IN, USA) stent grafts were available at the hospital. A redosternotomy was performed and a woven dacron graft prefabricated trifurcated graft 24x10x10x8 mm (Vascutek-Terumo, UK) was anastomosed end-to-side to the previous ascending aortic graft using a side-biting clamp; thus avoiding cardiopulmonary bypass. The 10 mm limb was anastomosed end-to-side to the innominate artery. The proximal innominate artery was oversewn without division. The 8 mm limb was anastomosed end-to-end to the transected left common carotid artery with the proximal end of the common carotid stump oversewn. Through the remaining 10 mm limb, a sheath and pigtail catheter was introduced antegrade into the arch. The ascending aortic graft had been measured from the CT scan at 37 mm in diameter. A 42 x 212 mm TX2 (Cook Inc., Bloomington, IN, USA) component was selected and introduced antegrade through the conduit, positioned and deployed from the descending thoracic aorta to the arch. As no tapered grafts were available, the substantial oversizing was accepted. The completion run showed a type 2 endoleak from the subclavian artery. The TX2 introduction sheath and imaging catheter were then removed and the access conduit transected and oversewn. The left subclavian artery was then ligated proximally (Figure 2).
The patient suffered a small cerebrovascular accident (CVA) with left-sided weakness which prompted a CT angiogram of the arch. The CT angiogram was performed which showed an endoleak from the innominate artery through a
Figure 3 18 months postop followup CT angiogram.
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gap in the suture line. An angiogram was performed via the right brachial artery and the gap cannulated and coils deployed effectively sealing the endoleak. The patient went on to have an uncomplicated postoperative course and recovered well from his CVA (Figure 3).
Discussion Aortic arch aneurysms are most often asymptomatic and their first presentation to a hospital is often with a rupture. This presents a difficult and complex surgical challenge. Open surgical management may be attempted, however there is significant morbidity and mortality associated. Pure endovascular treatment of the aortic arch may be performed, however in an emergency setting is unfeasible due to the custom-made nature of these devices. The development of the hybrid arch repair was to provide an alternative to conventional open surgical repair for patients previously unsuitable [1].
T. Nguyen et al.
Conclusion Hybrid aortic arch ruptured aneurysm repair is technically challenging but feasible and may avoid cardiopulmonary bypass and hypothermic circulatory arrest. The risk with placing a stent graft for repair of the aortic arch, however is whether the seal will maintain durability and whether migration of the stent graft will occur in future [2].
References [1] Szeto WY, Bavaria JE. Hybrid repair of aortic arch aneurysms: Combined open arch reconstruction and endovascular repair. Semin Thorac Cardiovasc Surg 2009;21:347–54. [2] Saleh HM. Hybrid repair of aortic arch aneurysm. Acta Chir Belg 2007;107:173–80. [3] Coppola R, Bonifazi R, Gucciardo M, Pantaleo P. Ruptured aortic arch aneurysm: transposition of aortic arch branches after insertion of thoracic endovascular stent with extra-anatomic brain perfusion. Interactive Cardiovascular and Thoracic Surgery 2007;6:376–8.
Heart, Lung and Circulation (2014) 23, e258–e260 1443-9506/04/$36.00 http://dx.doi.org/10.1016/j.hlc.2014.07.068
Hybrid Repair of an Aortic Arch Aneurysm Rupture in a Redo Sternotomy Tam Nguyen *, Matthew Claydon, Silvana Marasco Vascular Surgery Department, Alfred Hospital, Commercial Road, Prahran, Vic, 3181, Australia Received 25 January 2013; received in revised form 9 July 2014; accepted 23 July 2014; online published-ahead-of-print 15 August 2014
Purpose
To report a case of operative intervention for an aortic arch aneurysm rupture via a hybrid approach.
Methods and Results
Ten years after successful open repair of an acute type A aortic dissection a male presented with a rupture of his distal aortic arch aneurysm. A hybrid procedure was carried out which involved debranching of the innominate and left common carotid arteries and stent-graft deployment landing proximally into the ascending aorta and distally into the descending thoracic aorta.
Conclusions
Ruptured aortic arch aneurysms present a challenging and complex surgical dilemma. Open repair carries high mortality and pure endovascular repair is unfeasible; hence a hybrid repair presents an attractive solution.
Keywords
Aortic arch Aneurysm Rupture Hybrid repair
Introduction Conventional open repair of thoracic aortic aneurysms involving the aortic arch is associated with significant morbidity and mortality. Hybrid procedures have been developed to provide surgical options for elective patients previously at significantly high risk for conventional open repair and its application in the emergency treatment of a ruptured aortic arch aneurysm holds much promise [1,3]. We present a case report of a patient that presented to our hospital with a ruptured aortic arch aneurysm and was subsequently treated with a hybrid procedure through a redo sternotomy.
Case report A 70 year-old man presented to our institution with severe interscapular pain and hypotension. He had a history of an aortic valve and aortic dissection repair and ascending aortic graft replacement for an acute type A dissection performed 10 years prior. He had been lost to follow-up. An urgent CT
angiogram was performed which showed a large left-sided haemothorax contiguous with an arch aneurysm and persistent dissection in the proximal descending thoracic aorta extending to the iliac vessels. The diagnosis of a distal rupture of an aortic arch aneurysm was made (Figure 1). Extensive discussion occurred between the cardiothoracic and vascular teams to explore the various treatment options. Open thoracotomy and circulatory arrest followed by arch and descending thoracic aortic replacement was thought likely to result in certain death. A complete endovascular option would not be available in an emergency setting as a custom-made device would need to be designed and manufactured. A hybrid procedure was decided upon with a debranching procedure from the previous ascending aortic graft to the innominate and left common carotid artery planned and proximal ligation of the innominate, left common carotid artery and left subclavian artery. The ligation of left subclavian artery was planned for after graft deployment allowing its use for imaging access if this proved necessary. A conduit off the debranching graft would allow a stent graft to be deployed antegrade from the ascending aorta (landing ‘‘zone
*Corresponding author at: Vascular Surgery Department, Alfred Hospital, Commercial Road, Prahran, Vic, 3181, Australia., Email: [email protected] © 2014 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier Inc. All rights reserved.
e259
Hybrid Repair of an Aortic Arch
Figure 2 CT angiogram post hybrid repair.
Figure 1 CT angiogram showing ruptured aortic arch aneurysm.
0’’) to the descending aorta. A range of TX2 (Cook Inc., Bloomington, IN, USA) stent grafts were available at the hospital. A redosternotomy was performed and a woven dacron graft prefabricated trifurcated graft 24x10x10x8 mm (Vascutek-Terumo, UK) was anastomosed end-to-side to the previous ascending aortic graft using a side-biting clamp; thus avoiding cardiopulmonary bypass. The 10 mm limb was anastomosed end-to-side to the innominate artery. The proximal innominate artery was oversewn without division. The 8 mm limb was anastomosed end-to-end to the transected left common carotid artery with the proximal end of the common carotid stump oversewn. Through the remaining 10 mm limb, a sheath and pigtail catheter was introduced antegrade into the arch. The ascending aortic graft had been measured from the CT scan at 37 mm in diameter. A 42 x 212 mm TX2 (Cook Inc., Bloomington, IN, USA) component was selected and introduced antegrade through the conduit, positioned and deployed from the descending thoracic aorta to the arch. As no tapered grafts were available, the substantial oversizing was accepted. The completion run showed a type 2 endoleak from the subclavian artery. The TX2 introduction sheath and imaging catheter were then removed and the access conduit transected and oversewn. The left subclavian artery was then ligated proximally (Figure 2).
The patient suffered a small cerebrovascular accident (CVA) with left-sided weakness which prompted a CT angiogram of the arch. The CT angiogram was performed which showed an endoleak from the innominate artery through a
Figure 3 18 months postop followup CT angiogram.
e260
gap in the suture line. An angiogram was performed via the right brachial artery and the gap cannulated and coils deployed effectively sealing the endoleak. The patient went on to have an uncomplicated postoperative course and recovered well from his CVA (Figure 3).
Discussion Aortic arch aneurysms are most often asymptomatic and their first presentation to a hospital is often with a rupture. This presents a difficult and complex surgical challenge. Open surgical management may be attempted, however there is significant morbidity and mortality associated. Pure endovascular treatment of the aortic arch may be performed, however in an emergency setting is unfeasible due to the custom-made nature of these devices. The development of the hybrid arch repair was to provide an alternative to conventional open surgical repair for patients previously unsuitable [1].
T. Nguyen et al.
Conclusion Hybrid aortic arch ruptured aneurysm repair is technically challenging but feasible and may avoid cardiopulmonary bypass and hypothermic circulatory arrest. The risk with placing a stent graft for repair of the aortic arch, however is whether the seal will maintain durability and whether migration of the stent graft will occur in future [2].
References [1] Szeto WY, Bavaria JE. Hybrid repair of aortic arch aneurysms: Combined open arch reconstruction and endovascular repair. Semin Thorac Cardiovasc Surg 2009;21:347–54. [2] Saleh HM. Hybrid repair of aortic arch aneurysm. Acta Chir Belg 2007;107:173–80. [3] Coppola R, Bonifazi R, Gucciardo M, Pantaleo P. Ruptured aortic arch aneurysm: transposition of aortic arch branches after insertion of thoracic endovascular stent with extra-anatomic brain perfusion. Interactive Cardiovascular and Thoracic Surgery 2007;6:376–8.