- Email: [email protected]
Hybrid Repair of Ruptured Arch Aneurysm Without Sternotomy Through an Unusual Extraanatomic Bypass
Hybrid Repair of Ruptured Arch Aneurysm Without Sternotomy Through an Unusual Extraanatomic Bypass Chung-Lin Tsai, MD, Chih-Chun Yang, MD, Takuya Fujikawa, MD, and Shih-Rong Hsieh, MD, PhD Section of Cardiovascular Surgery, Taichung Veterans General Hospital, Taichung, Taiwan; and Section of Cardiovascular Surgery, Kawasaki Aortic Center, Kawasaki Saiwai Hospital, Kawasaki, Japan
A 42-year-old man experienced a complex aortic arch aneurysm rupture. He had previously undergone an operation for type A dissection and had extremely poor cardiac performance as well as deep sternal infection after the first procedure. The conventional open repair was considered to be a high risk for this patient. We therefore performed an alternative hybrid aortic procedure. The supraarch vessels were perfused through an
extraanatomic bypass from an unusual and remote route, namely, the abdominal aorta. Then, stent grafts were implanted in the previously replaced aortic prostheses to exclude the aortic aneurysm. The patient recovered uneventfully with no neurologic adverse events.
T
The bacterial culture from the bloodstream and the sternal wound revealed a Klebsiella pneumoniae infection. Additionally, the cardiac evaluation showed extremely low cardiac performance: Tc-99m-labeled red blood cells, left ventricular ejection fraction (LVEF) (multigated acquisition scan) 14.4%. A conventional open surgical procedure was considered too risky for several reasons: (1) the possibility that the aneurysm might rupture during sternal reentry, (2) the current mediastinitis, and (3) the patient’s extremely low LVEF. Thus, we decided to operate using a hybrid endovascular approach. Instead of attempting the standard hybrid method through a sternotomy, we reconstructed the supraaortic vessels with inflow from the abdominal aorta. A median laparotomy was performed by use of a 24-mm 12-mm 12-mm bifurcated gelatin-sealed polyester vascular graft (Gelsoft Plus, Vascutek Ltd, Renfrewshire, UK), which was anastomosed in the true lumen of the abdominal aorta. Then, two 12-mm polyester vascular grafts were anastomosed to each of the previous 12-mm limbs of the bifurcated graft and extended to the neck through a subcutaneous tunnel created through the chest wall. Because the two 12-mm grafts were laid on the subcutaneous layer of the chest wall without ring enhancement (12-mm ringed Gore-Tex graft was not available in our institution), we used a 16-mm Endurant II endoprosthesis (Medtronic, Inc, Minneapolis, MN) to insert into the 12-mm vascular grafts to prevent collapse. Finally, both common carotid arteries and subclavian arteries were exposed through a longitudinal and subclavicular incision in the neck. Two bifurcated 16-mm 8mm 8-mm ringed polytetrafluoroethylene vascular grafts were used for this reconstruction. The 16-mm
he hybrid endovascular arch approach has become recognized as a safe alternative for patients with multiple comorbidities [1]. For complicated operative conditions, a brachiocephalic bypass without sternotomy has also been demonstrated to be a feasible alternative approach. To accomplish a hybrid arch repair, the establishment of rerouted supraaortic vessels for cerebral perfusion is mandatory if the lesion involves an arch segment. Adequate inflow is routinely obtained antegrade from an ascending aorta. However, this might not be applicable if there is an acute anterior rupture or a deep sternal infection, or if a complex redo operation is required. We report the case of a complex, ruptured dissecting arch aneurysm, which was salvaged with a unique hybrid procedure.
Technique A 42-year-old man had a history of Stanford type A aortic dissection with cardiac tamponade and profound shock. He had received an emergent ascending aortic graft replacement along with extracorporeal membrane oxygenation support for poor recovery after the first procedure. One year later, he was referred to our institution because of bleeding from an ulcerative sternotomy wound. Computed tomographic aortography (CTA) showed a 7-cm aortic arch and a 6-cm descending aortic aneurysm with anterior rupture (Fig 1). Accepted for publication Aug 13, 2016. Address correspondence to Dr Tsai, Taichung Veterans General Hospital, Section of Cardiovascular Surgery, 1650 Taiwan Blvd Section 4, Taichung, Taiwan; email: [email protected].
Ó 2017 by The Society of Thoracic Surgeons Published by Elsevier
(Ann Thorac Surg 2017;103:e209–11) Ó 2017 by The Society of Thoracic Surgeons
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2016.08.039
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HOW TO DO IT TSAI ET AL HYBRID REPAIR OF RUPTURED ARCH ANEURYSM
Ann Thorac Surg 2017;103:e209–11
Fig 1. (A) Sagittal view. (B) Coronal view. Preoperative computed tomographic aortographic views showing a 7-cm aortic arch in B (white arrow), a 6-cm descending aortic aneurysm with anterior rupture in A (black arrow), and a mediastinal hematoma.
proximal side of the bifurcated graft was anastomosed to the previously extended 12-mm limb in the chest wall. Next, each distal end of the 8-mm branch was anastomosed to the common carotid artery in an end-to-end fashion (ligation of proximal stumps) and subclavian artery (endto-side fashion). After complete reconstruction of the supraaortic vessels, Gore TAG endoprostheses measuring 37 mm 20 cm, 37 mm 15 cm, and 31 mm 10cm (W.L. Gore & Assoc, Flagstaff, AZ) were implanted in Ishimaru zone 0, anchored within the previous replaced ascending aortic graft (Fig 2). Two Amplatzer vascular plugs (AGA Medical Corp, Plymouth, MN) were applied to occlude the backflow from the brachiocephalic and left subclavian arteries. There were no cerebral, renal, or visceral adverse events. The ulcerative sternotomy wound was debrided in stages. The patient was discharged on the 48th postoperative day. Three months after the procedure, a CTA scan showed effective exclusion of the lesion, and all bypass grafts were patent (Fig 3).
Comment When complex aortic conditions occur such as resternotomy, deep sternal infection, and adhesion, the surgical procedures are often technically challenging. Conventional approaches to the aforementioned conditions may put the patient at risk of instant damage to the aorta, catastrophic hemorrhage, and death [2]. The “hybrid” procedure has emerged as a valuable treatment for complex thoracic aortic diseases. It is mandatory to build up cerebral inflow before the hybrid approach can be attempted, and delicate cerebral inflow from the ascending aorta has been shown to be crucial. However, certain situations may preclude the rebuilding of sufficient cerebral flow. Only a handful of studies have described attempts to resolve this surgical challenge. Walterbusch and colleagues [3] first reported a case of restored carotid flow through the femorocarotid bypass during acute aortic dissection in 1984. Joyeux and colleagues [4] used temporary extraanatomic femorobicarotid bypass brain perfusion to treat a ruptured
Fig 2. (A) Anastomosis of one 24-mm 12-mm 12-mm bifurcated gelatin-sealed polyester vascular graft to the abdominal aortic true lumen. (B) Then, anastomosis of two 12-mm polyester vascular grafts to each of the previous 12-mm limbs of the bifurcated graft and extended to the neck through a subcutaneous tunnel created through the chest wall; insertion of a 16-mm Endurant II endoprosthesis into both 12-mm vascular grafts for reinforcement. (C) Anastomosis of another two bifurcated 16-mm 8-mm 8-mm vascular grafts to both carotid arteries and subclavian arteries. (D) Finally, implantation of Gore TAG endoprostheses measuring 37 mm 20 cm, 37 mm 15 cm, and 31 mm 10 cm within the previous replaced ascending aortic graft.
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Total endovascular approaches such as chimney, fenestrated, and branched stent grafts have recently been developed as options for aortic repair in patients who are unfit for conventional open operations [7]. However, owing to the postdissection complex aortic arch lamina of our patient, stenting of these fenestrated, branched grafts would likely have been inaccurate. In the procedure we performed, the inflow supplying the supraaortic vessels was from a remote origin, the abdominal aorta, which provided satisfactory perfusion without cerebral ischemia. This procedure offers an alternative solution in the treatment of conditions involving a complex aortic arch. The authors wish to thank Mr Peter Wilds for editing the language of this manuscript.
References
Fig 3. Computed tomographic angiogram 3 months after the procedure, showing effective exclusion of the ruptured arch aneurysm and patency of all bypass grafts.
arch aneurysm. The use of hybrid arch repair and supraaortic inflow from the descending aorta has also been reported [5, 6]. In the present case, the patient’s descending aorta segment was aneurysmal and dilated, with a complex dissection. Furthermore, the femoral artery is conventionally used to perfuse the supraaortic vessels and is theoretically considered to be a temporary route. Therefore, we created the permanent cerebral flow originating from the remote abdominal aorta. This unique procedure was capable of rescuing the patient from this devastating condition.
1. Milewski RK, Szeto WY, Pochettino A, Moser GM, Moeller P, Bavaria JE. Have hybrid procedures replaced open aortic arch reconstruction in high-risk patients? A comparative study of elective open arch debranching with endovascular stent graft placement and conventional elective open total and distal aortic arch reconstruction. J Thorac Cardiovasc Surg 2010;140: 590–7. 2. Follis FM, Pett SB Jr, Miller KB, Wong RS, Temes RT, Wernly JA. Catastrophic hemorrhage on sternal reentry: still a dreaded complication? Ann Thorac Surg 1999;68:2215–9. 3. Walterbusch G, Oelert H, Borst HG. Restoration of cerebral blood flow by extra-anatomic bypass in acute aortic dissection. Thorac Cardiovasc Surg 1984;32:381–2. 4. Joyeux F, Canaud L, Hireche K, Berthet JP, Marty-Ane C, Alric P. Temporary extra-anatomic brain perfusion followed by total rerouting of the supra-aortic vessels for hybrid repair of a ruptured aortic arch aneurysm. J Vasc Surg 2011;54: 1145–7. 5. Shimizu H, Hachiya T, Yamabe K, Yozu R. Hybrid arch repair including supra-aortic debranching on the descending aorta. Ann Thorac Surg 2011;92:2266–8. 6. Deriu G, Grego F, Frigatti P, et al. Unusual inflow sources and device introduction sites in aortic arch debranching. J Cardiovasc Surg 2012;53:143–51. 7. Haulon S, Greenberg RK, Spear R, et al. Global experience with an inner branched arch endograft. J Thorac Cardiovasc Surg 2014;48:1709–16.
A 42-year-old man experienced a complex aortic arch aneurysm rupture. He had previously undergone an operation for type A dissection and had extremely poor cardiac performance as well as deep sternal infection after the first procedure. The conventional open repair was considered to be a high risk for this patient. We therefore performed an alternative hybrid aortic procedure. The supraarch vessels were perfused through an
extraanatomic bypass from an unusual and remote route, namely, the abdominal aorta. Then, stent grafts were implanted in the previously replaced aortic prostheses to exclude the aortic aneurysm. The patient recovered uneventfully with no neurologic adverse events.
T
The bacterial culture from the bloodstream and the sternal wound revealed a Klebsiella pneumoniae infection. Additionally, the cardiac evaluation showed extremely low cardiac performance: Tc-99m-labeled red blood cells, left ventricular ejection fraction (LVEF) (multigated acquisition scan) 14.4%. A conventional open surgical procedure was considered too risky for several reasons: (1) the possibility that the aneurysm might rupture during sternal reentry, (2) the current mediastinitis, and (3) the patient’s extremely low LVEF. Thus, we decided to operate using a hybrid endovascular approach. Instead of attempting the standard hybrid method through a sternotomy, we reconstructed the supraaortic vessels with inflow from the abdominal aorta. A median laparotomy was performed by use of a 24-mm 12-mm 12-mm bifurcated gelatin-sealed polyester vascular graft (Gelsoft Plus, Vascutek Ltd, Renfrewshire, UK), which was anastomosed in the true lumen of the abdominal aorta. Then, two 12-mm polyester vascular grafts were anastomosed to each of the previous 12-mm limbs of the bifurcated graft and extended to the neck through a subcutaneous tunnel created through the chest wall. Because the two 12-mm grafts were laid on the subcutaneous layer of the chest wall without ring enhancement (12-mm ringed Gore-Tex graft was not available in our institution), we used a 16-mm Endurant II endoprosthesis (Medtronic, Inc, Minneapolis, MN) to insert into the 12-mm vascular grafts to prevent collapse. Finally, both common carotid arteries and subclavian arteries were exposed through a longitudinal and subclavicular incision in the neck. Two bifurcated 16-mm 8mm 8-mm ringed polytetrafluoroethylene vascular grafts were used for this reconstruction. The 16-mm
he hybrid endovascular arch approach has become recognized as a safe alternative for patients with multiple comorbidities [1]. For complicated operative conditions, a brachiocephalic bypass without sternotomy has also been demonstrated to be a feasible alternative approach. To accomplish a hybrid arch repair, the establishment of rerouted supraaortic vessels for cerebral perfusion is mandatory if the lesion involves an arch segment. Adequate inflow is routinely obtained antegrade from an ascending aorta. However, this might not be applicable if there is an acute anterior rupture or a deep sternal infection, or if a complex redo operation is required. We report the case of a complex, ruptured dissecting arch aneurysm, which was salvaged with a unique hybrid procedure.
Technique A 42-year-old man had a history of Stanford type A aortic dissection with cardiac tamponade and profound shock. He had received an emergent ascending aortic graft replacement along with extracorporeal membrane oxygenation support for poor recovery after the first procedure. One year later, he was referred to our institution because of bleeding from an ulcerative sternotomy wound. Computed tomographic aortography (CTA) showed a 7-cm aortic arch and a 6-cm descending aortic aneurysm with anterior rupture (Fig 1). Accepted for publication Aug 13, 2016. Address correspondence to Dr Tsai, Taichung Veterans General Hospital, Section of Cardiovascular Surgery, 1650 Taiwan Blvd Section 4, Taichung, Taiwan; email: [email protected].
Ó 2017 by The Society of Thoracic Surgeons Published by Elsevier
(Ann Thorac Surg 2017;103:e209–11) Ó 2017 by The Society of Thoracic Surgeons
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2016.08.039
e210
HOW TO DO IT TSAI ET AL HYBRID REPAIR OF RUPTURED ARCH ANEURYSM
Ann Thorac Surg 2017;103:e209–11
Fig 1. (A) Sagittal view. (B) Coronal view. Preoperative computed tomographic aortographic views showing a 7-cm aortic arch in B (white arrow), a 6-cm descending aortic aneurysm with anterior rupture in A (black arrow), and a mediastinal hematoma.
proximal side of the bifurcated graft was anastomosed to the previously extended 12-mm limb in the chest wall. Next, each distal end of the 8-mm branch was anastomosed to the common carotid artery in an end-to-end fashion (ligation of proximal stumps) and subclavian artery (endto-side fashion). After complete reconstruction of the supraaortic vessels, Gore TAG endoprostheses measuring 37 mm 20 cm, 37 mm 15 cm, and 31 mm 10cm (W.L. Gore & Assoc, Flagstaff, AZ) were implanted in Ishimaru zone 0, anchored within the previous replaced ascending aortic graft (Fig 2). Two Amplatzer vascular plugs (AGA Medical Corp, Plymouth, MN) were applied to occlude the backflow from the brachiocephalic and left subclavian arteries. There were no cerebral, renal, or visceral adverse events. The ulcerative sternotomy wound was debrided in stages. The patient was discharged on the 48th postoperative day. Three months after the procedure, a CTA scan showed effective exclusion of the lesion, and all bypass grafts were patent (Fig 3).
Comment When complex aortic conditions occur such as resternotomy, deep sternal infection, and adhesion, the surgical procedures are often technically challenging. Conventional approaches to the aforementioned conditions may put the patient at risk of instant damage to the aorta, catastrophic hemorrhage, and death [2]. The “hybrid” procedure has emerged as a valuable treatment for complex thoracic aortic diseases. It is mandatory to build up cerebral inflow before the hybrid approach can be attempted, and delicate cerebral inflow from the ascending aorta has been shown to be crucial. However, certain situations may preclude the rebuilding of sufficient cerebral flow. Only a handful of studies have described attempts to resolve this surgical challenge. Walterbusch and colleagues [3] first reported a case of restored carotid flow through the femorocarotid bypass during acute aortic dissection in 1984. Joyeux and colleagues [4] used temporary extraanatomic femorobicarotid bypass brain perfusion to treat a ruptured
Fig 2. (A) Anastomosis of one 24-mm 12-mm 12-mm bifurcated gelatin-sealed polyester vascular graft to the abdominal aortic true lumen. (B) Then, anastomosis of two 12-mm polyester vascular grafts to each of the previous 12-mm limbs of the bifurcated graft and extended to the neck through a subcutaneous tunnel created through the chest wall; insertion of a 16-mm Endurant II endoprosthesis into both 12-mm vascular grafts for reinforcement. (C) Anastomosis of another two bifurcated 16-mm 8-mm 8-mm vascular grafts to both carotid arteries and subclavian arteries. (D) Finally, implantation of Gore TAG endoprostheses measuring 37 mm 20 cm, 37 mm 15 cm, and 31 mm 10 cm within the previous replaced ascending aortic graft.
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Total endovascular approaches such as chimney, fenestrated, and branched stent grafts have recently been developed as options for aortic repair in patients who are unfit for conventional open operations [7]. However, owing to the postdissection complex aortic arch lamina of our patient, stenting of these fenestrated, branched grafts would likely have been inaccurate. In the procedure we performed, the inflow supplying the supraaortic vessels was from a remote origin, the abdominal aorta, which provided satisfactory perfusion without cerebral ischemia. This procedure offers an alternative solution in the treatment of conditions involving a complex aortic arch. The authors wish to thank Mr Peter Wilds for editing the language of this manuscript.
References
Fig 3. Computed tomographic angiogram 3 months after the procedure, showing effective exclusion of the ruptured arch aneurysm and patency of all bypass grafts.
arch aneurysm. The use of hybrid arch repair and supraaortic inflow from the descending aorta has also been reported [5, 6]. In the present case, the patient’s descending aorta segment was aneurysmal and dilated, with a complex dissection. Furthermore, the femoral artery is conventionally used to perfuse the supraaortic vessels and is theoretically considered to be a temporary route. Therefore, we created the permanent cerebral flow originating from the remote abdominal aorta. This unique procedure was capable of rescuing the patient from this devastating condition.
1. Milewski RK, Szeto WY, Pochettino A, Moser GM, Moeller P, Bavaria JE. Have hybrid procedures replaced open aortic arch reconstruction in high-risk patients? A comparative study of elective open arch debranching with endovascular stent graft placement and conventional elective open total and distal aortic arch reconstruction. J Thorac Cardiovasc Surg 2010;140: 590–7. 2. Follis FM, Pett SB Jr, Miller KB, Wong RS, Temes RT, Wernly JA. Catastrophic hemorrhage on sternal reentry: still a dreaded complication? Ann Thorac Surg 1999;68:2215–9. 3. Walterbusch G, Oelert H, Borst HG. Restoration of cerebral blood flow by extra-anatomic bypass in acute aortic dissection. Thorac Cardiovasc Surg 1984;32:381–2. 4. Joyeux F, Canaud L, Hireche K, Berthet JP, Marty-Ane C, Alric P. Temporary extra-anatomic brain perfusion followed by total rerouting of the supra-aortic vessels for hybrid repair of a ruptured aortic arch aneurysm. J Vasc Surg 2011;54: 1145–7. 5. Shimizu H, Hachiya T, Yamabe K, Yozu R. Hybrid arch repair including supra-aortic debranching on the descending aorta. Ann Thorac Surg 2011;92:2266–8. 6. Deriu G, Grego F, Frigatti P, et al. Unusual inflow sources and device introduction sites in aortic arch debranching. J Cardiovasc Surg 2012;53:143–51. 7. Haulon S, Greenberg RK, Spear R, et al. Global experience with an inner branched arch endograft. J Thorac Cardiovasc Surg 2014;48:1709–16.