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Clampless and Sutureless Hybrid Technique for Aortic Arch Debranching on a Porcelain Aorta
HOW TO DO IT
Clampless and Sutureless Hybrid Technique for Aortic Arch Debranching on a Porcelain Aorta Giorgio L. Poletto, MD, Liam Musto, Efrem Civilini, MD, and PierLuigi Giorgetti, MD Humanitas Clinical and Research Hospital, Rozzano, Italy
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 crossclamping may also provide a solution to approaching a porcelain aorta and difficult anatomies.
S
incisions. After systemic heparinization (5,000 IU), light palpation confirmed the situation of a porcelain aorta and coarse calcification of the innominate artery. A pursestring monofilament 7-0 suture reinforced with polytetrafluoroethylene felt pledglets was used to create a circumferential support on a small area (previously identified on the CT scan) devoid of calcification on the ascending aorta. By direct puncture of the ascending aorta with an introducer needle, a standard hydrophilic guidewire (Terumo Glidewire 0.3500 ) was inserted under direct view for about 15 cm (Fig 1A). Under rapid ventricular pacing, a small aortotomy (approximately 3 mm) was performed, and the stentsupported tract of an 8-mm Gore hybrid vascular prosthesis was then inserted for approximately 3 cm into the aortic arch. The graft was delivered under cardiac pacing (20 s) over the guidewire with no need for cross-clamping; hemostasis was achieved by gentle pulling and ligation of the pursestring (Fig 1B). Under fluoroscopy a balloonexpandable stent (10 mm 25 mm) was inflated (6 atm) across the entry point of the prosthesis point to accurately dilate the sutureless anastomosis to its nominal diameter. Two more Gore hybrid prostheses (8 mm and 7 mm) were stitched to the end of the first prosthesis to form a bifurcated graft (Fig 2A). The crossover connecting the two carotids was incised, and two thirds of the reinforced portions of the bifurcate graft were inserted into each common carotid at the level of the distal and proximal stump of the crossover, with no need for suturing or clamping of the carotid arteries (Fig 2B). The native vessels were ligated and oversewn, Completion angiography revealed optimum patency of the graft. The patient tolerated the procedure well, with no postoperative adverse events, and was discharged on the seventh postoperative day to receive 6-month dual antiplatelet therapy. At the 6-month follow-up visit, the patient was alive and well, with no further neurologic symptoms. An angiographic CT scan confirmed regular surgical results with slight kinking of the left carotid artery (Fig 3), not accompanied by increased peak velocity at duplex ultrasonography.
Technique After informed consent was obtained and with the patient under near infrared spectroscopy (NIRS) monitoring, the ascending aorta and the carotid crossover were exposed through a median sternotomy and bilateral cervical Accepted for publication Dec 9, 2015. Address correspondence to Dr Poletto, Vascular Surgery I, Humanitas Clinical and Research Hospital, Via A Manzoni, 56, 20089 Rozzano, Italy; email: [email protected].
Ó 2016 by The Society of Thoracic Surgeons Published by Elsevier
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.12.023
FEATURE ARTICLES
upraaortic branches can be surgically treated with bypass or endarterectomy. A porcelain aorta is, however, a contraindication to cross-clamping because of the high risk of aortic embolization, dissection, or even rupture [1]. The VORTEC (Viabahn Open Revascularization TEChnique) has been recently introduced into clinical practice for a clampless and sutureless anastomosis, with interesting results [2, 3]. Building on this technique and using novel vascular grafts, we treated a high-risk patient who had supraaortic vessels, stenoocclusion, and a porcelain aorta. An 80-year-old woman with hypertension, dyslipidemia, and dilated cardiomyopathy (ejection fraction <30%, stage C American College of Cardiiology / American Heart Association) was admitted to our hospital for recurrent transient ischemic attacks (TIAs) presenting with amaurosis and hyposthenia. Eleven years before our intervention, the patient underwent endovascular stenting of the proximal left common carotid. She then underwent reoperated because of a subocclusion of the stent and underwent rightto-left carotid crossover bypass. Angiographic computed tomographic (CT) evaluation of the supraaortic branches revealed preocclusive calcific stenosis of the innominate artery and an anastomotic restenosis of the crossover bypass associated with a so-called porcelain aorta. Given that this is a contraindication for aortic cross-clamping, after a failed endovascular attempt because the patient experienced a TIA as a consequence of an ineffective balloon angioplasty, we decided to move to a hybrid solution.
(Ann Thorac Surg 2016;101:2395–7) Ó 2016 by The Society of Thoracic Surgeons
2396
HOW TO DO IT POLETTO ET AL HYBRID TECHNIQUE FOR AORTIC ARCH DEBRANCHING
Ann Thorac Surg 2016;101:2395–7
FEATURE ARTICLES
Fig 1. (A) Intraoperative identification of the small area devoid of calcification. The pledget-lined pursestring suture is fixed around the puncture site. By needle puncture (arrow), a guidewire is inserted into the ascending aorta. (B) The hybrid graft is inserted over the guidewire and opened with a trigger-wire mechanism, achieving an adequate run-in.
Comment Surgical options with either an innominate artery/left common carotid artery endarterectomy or aortic arch Fig 2. (A) A Y graft is customized by tailoring two more hybrid grafts to the inflow branch. (B) Bilateral carotid revascularization is accomplished by sutureless attachment of the two grafts to the crossover graft previously implanted.
rerouting were contraindicated because of the use of cross-clamping to a porcelain aorta. Conservative treatment was not an option because the patient was receiving
Ann Thorac Surg 2016;101:2395–7
HOW TO DO IT POLETTO ET AL HYBRID TECHNIQUE FOR AORTIC ARCH DEBRANCHING
2397
Fig 3. (A) Postoperative computed tomographic view of reconstructed aortic arch and bifurcated graft. Extensive calcifications of the ascending aorta are detailed: a small anterior area devoid of pathologic changes is allowed, to obtain an inflow site. (B) Three-dimensional maximum intensity projection (MIP) visualization showing the amount and behavior of the hybrid graft inserted into the ascending aorta.
may enhance our surgical indications, and ever-improving technical advances will increase the number of patients we can safely treat, despite the economic costs. In conclusion, in the aforementioned case, the improved ability to manage open and endovascular surgical procedures allowed an effective hybrid treatment of an extremely high-risk patient. Novel prosthetic vascular grafts that can be applied without cross-clamping may also provide a solution to a porcelain aorta.
References 1. Abramowitz Y, Jilaihawi H, Chakravarty T, et al. Porcelain aorta: a comprehensive review. Circulation 2015;131:827–36. 2. Lachat M, Mayer D, Criado FJ, et al. New technique to facilitate renal revascularization with use of telescoping selfexpanding stent grafts: VORTEC. Vascular 2008;16:69–72. 3. Donas KP, Rancic Z, Lachat M, et al. Novel sutureless telescoping anastomosis revascularization technique of supraaortic vessels to simplify combined open endovascular procedures in the treatment of aortic arch pathologies. J Vasc Surg 2010;51:836–41. 4. Levack MM, Bavaria JE, Gorman RC, et al. Rapid aortic arch debranching using the Gore hybrid vascular graft. Ann Thorac Surg 2013;95:e163–5. 5. Bonvini S, Zavatta M, Grego F, Piazza M. Aortic hybrid sutureless anastomosis on porcelain aorta. J Endovasc Ther 2015;22:194–7. 6. Chiesa R, Kahlberg A, Mascia D, Tshomba Y, Civilini E, Melissano G. Use of a novel hybrid vascular graft for sutureless revascularization of the renal arteries during open thoraacoabdominal aortic aneurysm repair. J Vasc Surg 2014;60:622–30. 7. Willaert W, Claes K, Flamme A, Jacobs B. Initial experience with a novel hybrid vascular graft for peripheral artery disease. J Cardiovasc Surg (Torino) 2014 Mar 4; [Epub ahead of print]. 8. GORE Hybrid vascular graft: instructions for use—English. Available at http://www.goremedical.com/hybrid/instructions/. Accessed April 7, 2015.
FEATURE ARTICLES
maximal medical treatment and was still experiencing recurrent TIAs. A clampless hybrid procedure was the only solution we could foresee. Sutureless anastomoses with covered self-expanding stents such as the VORTEC (Viabahn Open Revascularisation TEChnique) have been described for several anatomic areas with technical success [3, 4, 5]. The Gore hybrid vascular graft (GHVG), to our knowledge currently the only available device with these features, represents the natural evolution of these techniques. Chiesa and colleagues [6] used the GHVG to revascularize the renal arteries during open repair of a thoracoabdominal aortic aneurysm, with results comparable with those of standard techniques. Willaert and colleagues [7] used the GHVG for an above-knee femoropopliteal bypass operation, avoiding the necessity of an infragenicular bypass. We believe this is one of the first reports to describe the use of hybrid grafts on the ascending aorta and also in such a manner (off-label use). In the instruction for use (IFU) the GHVG requires a landing zone of at least 2.5 cm, but the aortic wall in this patient provided a landing zone of only a few milllimeters [8]. The limited area of uncalcified aorta led to the choice of an 8-mm graft (potentially small to supply blood to the brain), although a larger one was available. Circumferential stitching and a balloon expandable stent were adequate to secure the graft in place, but the issue is what would have been the appropriate action if the anastomosis had failed; our bailout plan was to use a pursestring suture closure around the graft entry point and to end the operation. However, there are many advantages: the ability to apply the graft rapidly and in a timely fashion reduces potential ischemia time and avoidance of clamping a porcelain aorta as highlighted, and it reduces the risk of aortic embolization or dissection [1]. Hybrid operations
Clampless and Sutureless Hybrid Technique for Aortic Arch Debranching on a Porcelain Aorta Giorgio L. Poletto, MD, Liam Musto, Efrem Civilini, MD, and PierLuigi Giorgetti, MD Humanitas Clinical and Research Hospital, Rozzano, Italy
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 crossclamping may also provide a solution to approaching a porcelain aorta and difficult anatomies.
S
incisions. After systemic heparinization (5,000 IU), light palpation confirmed the situation of a porcelain aorta and coarse calcification of the innominate artery. A pursestring monofilament 7-0 suture reinforced with polytetrafluoroethylene felt pledglets was used to create a circumferential support on a small area (previously identified on the CT scan) devoid of calcification on the ascending aorta. By direct puncture of the ascending aorta with an introducer needle, a standard hydrophilic guidewire (Terumo Glidewire 0.3500 ) was inserted under direct view for about 15 cm (Fig 1A). Under rapid ventricular pacing, a small aortotomy (approximately 3 mm) was performed, and the stentsupported tract of an 8-mm Gore hybrid vascular prosthesis was then inserted for approximately 3 cm into the aortic arch. The graft was delivered under cardiac pacing (20 s) over the guidewire with no need for cross-clamping; hemostasis was achieved by gentle pulling and ligation of the pursestring (Fig 1B). Under fluoroscopy a balloonexpandable stent (10 mm 25 mm) was inflated (6 atm) across the entry point of the prosthesis point to accurately dilate the sutureless anastomosis to its nominal diameter. Two more Gore hybrid prostheses (8 mm and 7 mm) were stitched to the end of the first prosthesis to form a bifurcated graft (Fig 2A). The crossover connecting the two carotids was incised, and two thirds of the reinforced portions of the bifurcate graft were inserted into each common carotid at the level of the distal and proximal stump of the crossover, with no need for suturing or clamping of the carotid arteries (Fig 2B). The native vessels were ligated and oversewn, Completion angiography revealed optimum patency of the graft. The patient tolerated the procedure well, with no postoperative adverse events, and was discharged on the seventh postoperative day to receive 6-month dual antiplatelet therapy. At the 6-month follow-up visit, the patient was alive and well, with no further neurologic symptoms. An angiographic CT scan confirmed regular surgical results with slight kinking of the left carotid artery (Fig 3), not accompanied by increased peak velocity at duplex ultrasonography.
Technique After informed consent was obtained and with the patient under near infrared spectroscopy (NIRS) monitoring, the ascending aorta and the carotid crossover were exposed through a median sternotomy and bilateral cervical Accepted for publication Dec 9, 2015. Address correspondence to Dr Poletto, Vascular Surgery I, Humanitas Clinical and Research Hospital, Via A Manzoni, 56, 20089 Rozzano, Italy; email: [email protected].
Ó 2016 by The Society of Thoracic Surgeons Published by Elsevier
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.12.023
FEATURE ARTICLES
upraaortic branches can be surgically treated with bypass or endarterectomy. A porcelain aorta is, however, a contraindication to cross-clamping because of the high risk of aortic embolization, dissection, or even rupture [1]. The VORTEC (Viabahn Open Revascularization TEChnique) has been recently introduced into clinical practice for a clampless and sutureless anastomosis, with interesting results [2, 3]. Building on this technique and using novel vascular grafts, we treated a high-risk patient who had supraaortic vessels, stenoocclusion, and a porcelain aorta. An 80-year-old woman with hypertension, dyslipidemia, and dilated cardiomyopathy (ejection fraction <30%, stage C American College of Cardiiology / American Heart Association) was admitted to our hospital for recurrent transient ischemic attacks (TIAs) presenting with amaurosis and hyposthenia. Eleven years before our intervention, the patient underwent endovascular stenting of the proximal left common carotid. She then underwent reoperated because of a subocclusion of the stent and underwent rightto-left carotid crossover bypass. Angiographic computed tomographic (CT) evaluation of the supraaortic branches revealed preocclusive calcific stenosis of the innominate artery and an anastomotic restenosis of the crossover bypass associated with a so-called porcelain aorta. Given that this is a contraindication for aortic cross-clamping, after a failed endovascular attempt because the patient experienced a TIA as a consequence of an ineffective balloon angioplasty, we decided to move to a hybrid solution.
(Ann Thorac Surg 2016;101:2395–7) Ó 2016 by The Society of Thoracic Surgeons
2396
HOW TO DO IT POLETTO ET AL HYBRID TECHNIQUE FOR AORTIC ARCH DEBRANCHING
Ann Thorac Surg 2016;101:2395–7
FEATURE ARTICLES
Fig 1. (A) Intraoperative identification of the small area devoid of calcification. The pledget-lined pursestring suture is fixed around the puncture site. By needle puncture (arrow), a guidewire is inserted into the ascending aorta. (B) The hybrid graft is inserted over the guidewire and opened with a trigger-wire mechanism, achieving an adequate run-in.
Comment Surgical options with either an innominate artery/left common carotid artery endarterectomy or aortic arch Fig 2. (A) A Y graft is customized by tailoring two more hybrid grafts to the inflow branch. (B) Bilateral carotid revascularization is accomplished by sutureless attachment of the two grafts to the crossover graft previously implanted.
rerouting were contraindicated because of the use of cross-clamping to a porcelain aorta. Conservative treatment was not an option because the patient was receiving
Ann Thorac Surg 2016;101:2395–7
HOW TO DO IT POLETTO ET AL HYBRID TECHNIQUE FOR AORTIC ARCH DEBRANCHING
2397
Fig 3. (A) Postoperative computed tomographic view of reconstructed aortic arch and bifurcated graft. Extensive calcifications of the ascending aorta are detailed: a small anterior area devoid of pathologic changes is allowed, to obtain an inflow site. (B) Three-dimensional maximum intensity projection (MIP) visualization showing the amount and behavior of the hybrid graft inserted into the ascending aorta.
may enhance our surgical indications, and ever-improving technical advances will increase the number of patients we can safely treat, despite the economic costs. In conclusion, in the aforementioned case, the improved ability to manage open and endovascular surgical procedures allowed an effective hybrid treatment of an extremely high-risk patient. Novel prosthetic vascular grafts that can be applied without cross-clamping may also provide a solution to a porcelain aorta.
References 1. Abramowitz Y, Jilaihawi H, Chakravarty T, et al. Porcelain aorta: a comprehensive review. Circulation 2015;131:827–36. 2. Lachat M, Mayer D, Criado FJ, et al. New technique to facilitate renal revascularization with use of telescoping selfexpanding stent grafts: VORTEC. Vascular 2008;16:69–72. 3. Donas KP, Rancic Z, Lachat M, et al. Novel sutureless telescoping anastomosis revascularization technique of supraaortic vessels to simplify combined open endovascular procedures in the treatment of aortic arch pathologies. J Vasc Surg 2010;51:836–41. 4. Levack MM, Bavaria JE, Gorman RC, et al. Rapid aortic arch debranching using the Gore hybrid vascular graft. Ann Thorac Surg 2013;95:e163–5. 5. Bonvini S, Zavatta M, Grego F, Piazza M. Aortic hybrid sutureless anastomosis on porcelain aorta. J Endovasc Ther 2015;22:194–7. 6. Chiesa R, Kahlberg A, Mascia D, Tshomba Y, Civilini E, Melissano G. Use of a novel hybrid vascular graft for sutureless revascularization of the renal arteries during open thoraacoabdominal aortic aneurysm repair. J Vasc Surg 2014;60:622–30. 7. Willaert W, Claes K, Flamme A, Jacobs B. Initial experience with a novel hybrid vascular graft for peripheral artery disease. J Cardiovasc Surg (Torino) 2014 Mar 4; [Epub ahead of print]. 8. GORE Hybrid vascular graft: instructions for use—English. Available at http://www.goremedical.com/hybrid/instructions/. Accessed April 7, 2015.
FEATURE ARTICLES
maximal medical treatment and was still experiencing recurrent TIAs. A clampless hybrid procedure was the only solution we could foresee. Sutureless anastomoses with covered self-expanding stents such as the VORTEC (Viabahn Open Revascularisation TEChnique) have been described for several anatomic areas with technical success [3, 4, 5]. The Gore hybrid vascular graft (GHVG), to our knowledge currently the only available device with these features, represents the natural evolution of these techniques. Chiesa and colleagues [6] used the GHVG to revascularize the renal arteries during open repair of a thoracoabdominal aortic aneurysm, with results comparable with those of standard techniques. Willaert and colleagues [7] used the GHVG for an above-knee femoropopliteal bypass operation, avoiding the necessity of an infragenicular bypass. We believe this is one of the first reports to describe the use of hybrid grafts on the ascending aorta and also in such a manner (off-label use). In the instruction for use (IFU) the GHVG requires a landing zone of at least 2.5 cm, but the aortic wall in this patient provided a landing zone of only a few milllimeters [8]. The limited area of uncalcified aorta led to the choice of an 8-mm graft (potentially small to supply blood to the brain), although a larger one was available. Circumferential stitching and a balloon expandable stent were adequate to secure the graft in place, but the issue is what would have been the appropriate action if the anastomosis had failed; our bailout plan was to use a pursestring suture closure around the graft entry point and to end the operation. However, there are many advantages: the ability to apply the graft rapidly and in a timely fashion reduces potential ischemia time and avoidance of clamping a porcelain aorta as highlighted, and it reduces the risk of aortic embolization or dissection [1]. Hybrid operations