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Endovascular Repair of an Aortic Arch Aneurysm using a Branched-Stent Graft
Eur J Vasc Endovasc Surg (2008) 36, 545e549
SHORT REPORT
Endovascular Repair of an Aortic Arch Aneurysm using a Branched-Stent Graft R. Brar, T. Ali, R. Morgan, I. Loftus, M. Thompson* St George’s Vascular Institute, 4th Floor St James’ Wing, St George’s Hospital NHS Trust, Blackshaw Road, London SW17 0QT, UK Submitted 8 April 2008; accepted 29 June 2008 Available online 21 August 2008
KEYWORDS Thoracic aorta; Endovascular aneurysm repair; Aneurysm; Branched stent graft; Transient cardiac asystole
Abstract Introduction: Aortic arch aneurysm repair continues to pose a formidable technical challenge in a patient population with significant co-morbidity. Report: We present a successful endovascular repair of an 8.4 cm aortic arch aneurysm, in a 74 year old man, who’s previous median sternotomy showed signs of delayed healing, precluding open repair. Discussion: Applied endovascular techniques obviated the need for aortic clamping, cardiac bypass, or hypothermic circulatory arrest, via an approach that was potentially infected. ª 2008 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.
Introduction
Report
Aortic arch aneurysm repair continues to pose a formidable technical challenge in a patient population with significant co-morbidity. We present a successful endovascular repair of a complex 8.4 cm arch aneurysm.
A 74 year old man presented with an 8.4 cm aortic arch aneurysm, involving the origins of innominate, left common carotid and left subclavian arteries (Figs. 1 and 4). Previous triple vessel coronary surgery (including LIMA to LAD) was complicated by methecillin resistant Staphylococcus Aureus sternal wound infection. Signs of delayed healing were still present which precluded a repeat sternotomy. An endovascular approach was therefore considered. Right-to-left carotid-carotid, and left carotid-subclavian (end-to-side) bypasses were fashioned. Due to the large diameter of the introducer system (25F), a 10 mm Dacron access conduit was anastamosed to the innominate bifurcation (Fig. 4). A Lunderquist guide-wire (COOK Medical,
* Corresponding author. M. Thompson MD, FRCS, St George’s Vascular Institute, 4th Floor St James’ Wing, St George’s Hospital NHS Trust, Blackshaw Road, London SW17 0QT, UK. Tel.: þ44 208 725 3205; fax: þ44 208 725 3495. E-mail address: [email protected] (M. Thompson).
1078-5884/$34 ª 2008 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ejvs.2008.06.033
546
Figure 1
R. Brar et al.
Transverse CT Aortogram showing 8.4 cm arch aneurysm before (AeC) and after (DeF) branched-stent graft repair.
Denmark) was passed via the conduit and coiled in the left ventricle. The custom-made COOK Zenith bifurcated endograft was passed over this extra-stiff guide-wire into the ascending aorta (the nose of the deployment system passing through the aortic valve) under fluoroscopic guidance, and deployed just distal to the coronary grafts (Figs. 2 and 4). Transient cardiac asystole was induced during stent deployment, by trans-venous over-pacing of the right ventricle. This facilitated accurate placement in the
aneurysm neck, preserving coronary graft patency and avoiding endoleak. A second (COOK Zenith distal thoracic) stent graft was deployed via femoral arterial access, overlapping within the distal lumen of the ascending aortic component, excluding the aneurysm. No problems of stent migration were encountered. Post-procedural imaging demonstrates the graft correctly positioned (Figs. 1e3).
Endovascular Repair of an Aortic Arch Aneurysm
547
Figure 2 Intra-operative fluoroscopic images. A. Angiogram showing patent coronary grafts; arch aneurysm; carotid-carotid and carotid-subclavian bypass grafts. B. Branched-stent graft deployed. C and D. Innominate branch deployment. E. Descending component deployment. F. Completion angiogram; aneurysm excluded and coronary grafts patent.
548
R. Brar et al.
Discussion Both hybrid1 and entirely endovascular2 techniques to treat aortic arch aneurysms have been described, offering useful alternatives to open repair3 in selected patients. In this instance, applied endovascular techniques obviated the need for aortic clamping, cardiac bypass or hypothermic circulatory arrest, through an approach that was potentially infected. Pharmacologically and electrically induced transient cardiac asystole during aortic stent placement have been described.4,5 Cardiac over-pacing allows excellent control while minimising circulatory arrest time. A custom-made stent-graft was required, which took three months to manufacture and transport. Close proximity of neck wounds and underlying grafts to the potentially infected field (SWI) demanded meticulous wound-care. Delayed healing was encountered, but no infection proven. Endovascular treatment of pathologies affecting the ascending aorta and aortic arch is feasible, but technical difficulties with graft design and deployment persist.
Figure 3 Postoperative reconstructed CTA (anterior view) showing branched-stent graft in position. Pacing wire (in IVC), visceral arteries and overlying contrast enhanced left brachiocephalic vein are evident.
Figure 4 Line drawings. A. Aneurysmal arch with carotid-carotid (1,2) and carotid-subclavian (3,4) bypass grafts, and a 10 mm Dacron conduit (5) anastamosed to the innominate bifurcation; B. Sheath introduced to ascending aorta via conduit and branched-stent graft being deployed; C. Sheath introduced via femoral artery and descending component of graft being deployed. Conduit oversewn and left in situ (6); D. Left common carotid and subclavian arteries tied off (7,8). Branched-stent graft deployed; E. Blood flow through branched-stent graft.
Endovascular Repair of an Aortic Arch Aneurysm
References 1 Chuter TA, Schneider DB, Reilly LM, Lobo EP, Messina LM. Modular branched stent graft for endovascular repair of aortic arch aneurysm and dissection. J Vasc Surg 2003;38(4):859e63. 2 Saito N, Kimura T, Toma M, Kita T, Inoko M, Nohara R, et al. Endovascular treatment of a giant aortic arch aneurysm with a triple-branched stent graft. Circulation 2005; 112:151e2.
549 3 Kikuchi Y, Sakurada T, Nakajima S, Koushima R, Kusajima K. Total aortic arch replacement for distal aortic arch aneurysms. English Abstract. Kyobu Geka 1998;51(1):58e62. 4 Moon MC, Dowdall JF, Roselli EE. The use of right ventricular pacing to facilitate stent graft deployment in the distal aortic arch. J Vasc Surg 2008;47(3):629e31. 5 Dorros G, Cohn JM. Adenosine-induced transient cardiac asystole enhances precise deployment of stent-grafts in the thoracic or abdominal aorta. J Endovasc Surg 1996;3:270e2.
SHORT REPORT
Endovascular Repair of an Aortic Arch Aneurysm using a Branched-Stent Graft R. Brar, T. Ali, R. Morgan, I. Loftus, M. Thompson* St George’s Vascular Institute, 4th Floor St James’ Wing, St George’s Hospital NHS Trust, Blackshaw Road, London SW17 0QT, UK Submitted 8 April 2008; accepted 29 June 2008 Available online 21 August 2008
KEYWORDS Thoracic aorta; Endovascular aneurysm repair; Aneurysm; Branched stent graft; Transient cardiac asystole
Abstract Introduction: Aortic arch aneurysm repair continues to pose a formidable technical challenge in a patient population with significant co-morbidity. Report: We present a successful endovascular repair of an 8.4 cm aortic arch aneurysm, in a 74 year old man, who’s previous median sternotomy showed signs of delayed healing, precluding open repair. Discussion: Applied endovascular techniques obviated the need for aortic clamping, cardiac bypass, or hypothermic circulatory arrest, via an approach that was potentially infected. ª 2008 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.
Introduction
Report
Aortic arch aneurysm repair continues to pose a formidable technical challenge in a patient population with significant co-morbidity. We present a successful endovascular repair of a complex 8.4 cm arch aneurysm.
A 74 year old man presented with an 8.4 cm aortic arch aneurysm, involving the origins of innominate, left common carotid and left subclavian arteries (Figs. 1 and 4). Previous triple vessel coronary surgery (including LIMA to LAD) was complicated by methecillin resistant Staphylococcus Aureus sternal wound infection. Signs of delayed healing were still present which precluded a repeat sternotomy. An endovascular approach was therefore considered. Right-to-left carotid-carotid, and left carotid-subclavian (end-to-side) bypasses were fashioned. Due to the large diameter of the introducer system (25F), a 10 mm Dacron access conduit was anastamosed to the innominate bifurcation (Fig. 4). A Lunderquist guide-wire (COOK Medical,
* Corresponding author. M. Thompson MD, FRCS, St George’s Vascular Institute, 4th Floor St James’ Wing, St George’s Hospital NHS Trust, Blackshaw Road, London SW17 0QT, UK. Tel.: þ44 208 725 3205; fax: þ44 208 725 3495. E-mail address: [email protected] (M. Thompson).
1078-5884/$34 ª 2008 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ejvs.2008.06.033
546
Figure 1
R. Brar et al.
Transverse CT Aortogram showing 8.4 cm arch aneurysm before (AeC) and after (DeF) branched-stent graft repair.
Denmark) was passed via the conduit and coiled in the left ventricle. The custom-made COOK Zenith bifurcated endograft was passed over this extra-stiff guide-wire into the ascending aorta (the nose of the deployment system passing through the aortic valve) under fluoroscopic guidance, and deployed just distal to the coronary grafts (Figs. 2 and 4). Transient cardiac asystole was induced during stent deployment, by trans-venous over-pacing of the right ventricle. This facilitated accurate placement in the
aneurysm neck, preserving coronary graft patency and avoiding endoleak. A second (COOK Zenith distal thoracic) stent graft was deployed via femoral arterial access, overlapping within the distal lumen of the ascending aortic component, excluding the aneurysm. No problems of stent migration were encountered. Post-procedural imaging demonstrates the graft correctly positioned (Figs. 1e3).
Endovascular Repair of an Aortic Arch Aneurysm
547
Figure 2 Intra-operative fluoroscopic images. A. Angiogram showing patent coronary grafts; arch aneurysm; carotid-carotid and carotid-subclavian bypass grafts. B. Branched-stent graft deployed. C and D. Innominate branch deployment. E. Descending component deployment. F. Completion angiogram; aneurysm excluded and coronary grafts patent.
548
R. Brar et al.
Discussion Both hybrid1 and entirely endovascular2 techniques to treat aortic arch aneurysms have been described, offering useful alternatives to open repair3 in selected patients. In this instance, applied endovascular techniques obviated the need for aortic clamping, cardiac bypass or hypothermic circulatory arrest, through an approach that was potentially infected. Pharmacologically and electrically induced transient cardiac asystole during aortic stent placement have been described.4,5 Cardiac over-pacing allows excellent control while minimising circulatory arrest time. A custom-made stent-graft was required, which took three months to manufacture and transport. Close proximity of neck wounds and underlying grafts to the potentially infected field (SWI) demanded meticulous wound-care. Delayed healing was encountered, but no infection proven. Endovascular treatment of pathologies affecting the ascending aorta and aortic arch is feasible, but technical difficulties with graft design and deployment persist.
Figure 3 Postoperative reconstructed CTA (anterior view) showing branched-stent graft in position. Pacing wire (in IVC), visceral arteries and overlying contrast enhanced left brachiocephalic vein are evident.
Figure 4 Line drawings. A. Aneurysmal arch with carotid-carotid (1,2) and carotid-subclavian (3,4) bypass grafts, and a 10 mm Dacron conduit (5) anastamosed to the innominate bifurcation; B. Sheath introduced to ascending aorta via conduit and branched-stent graft being deployed; C. Sheath introduced via femoral artery and descending component of graft being deployed. Conduit oversewn and left in situ (6); D. Left common carotid and subclavian arteries tied off (7,8). Branched-stent graft deployed; E. Blood flow through branched-stent graft.
Endovascular Repair of an Aortic Arch Aneurysm
References 1 Chuter TA, Schneider DB, Reilly LM, Lobo EP, Messina LM. Modular branched stent graft for endovascular repair of aortic arch aneurysm and dissection. J Vasc Surg 2003;38(4):859e63. 2 Saito N, Kimura T, Toma M, Kita T, Inoko M, Nohara R, et al. Endovascular treatment of a giant aortic arch aneurysm with a triple-branched stent graft. Circulation 2005; 112:151e2.
549 3 Kikuchi Y, Sakurada T, Nakajima S, Koushima R, Kusajima K. Total aortic arch replacement for distal aortic arch aneurysms. English Abstract. Kyobu Geka 1998;51(1):58e62. 4 Moon MC, Dowdall JF, Roselli EE. The use of right ventricular pacing to facilitate stent graft deployment in the distal aortic arch. J Vasc Surg 2008;47(3):629e31. 5 Dorros G, Cohn JM. Adenosine-induced transient cardiac asystole enhances precise deployment of stent-grafts in the thoracic or abdominal aorta. J Endovasc Surg 1996;3:270e2.