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Sandwich Techniques
Case Report Total Endovascular Aortic arch Replacement with Chimney/Sandwich Techniques Gabriela Teixeira,1 Arlindo Matos,1 Rui de Almeida,1 and Armando C. Lobato,2 Oporto, Portugal and S~ ao Paulo, Brazil
Traditional open total zone 0 replacement of the aortic arch is one of the most complex, challenging, and demanding operative procedures in cardiovascular surgery, associated with significant morbidity (30e40%) and mortality (8e20%). Total endovascular zone 0 replacement of the aortic arch with chimney/sandwich techniques as described by Lobato and Camacho-Lobato is a feasible, less invasive, less demanding, and time-consuming option to hybrid and/or traditional open replacement of the aortic arch, particularly in the urgent/emergent settings. We are reporting a case of a 49-year-old patient with chronic type B aortic dissection complicated with descending thoracic aortic aneurysm and an unsuccessful zone 3 thoracic endovascular aortic repair, complicated with type Ia endoleak. He presented with an enlarging and symptomatic descending thoracic aortic aneurysm. An extended proximal (to the zone 0) and distal thoracic endovascular aortic repair was performed to ensure appropriate proximal and distal landing zones (C-TAG). Left subclavian artery endorevascularization was undertaken with periscope sandwich technique (Viabahn), while brachiocephalic trunk and left carotid artery endorevascularizations were carried on with the chimney graft technique (Viabahn). The procedure was uneventful and the one-month and one-year follow-up angioecomputed tomography revealed no endoleaks, patency of all branches, and exclusion of the aneurysm.
The treatment of patients with large aneurysms of the aortic arch often represents a challenge due to the complexity of the procedure. Advances in endovascular technology has allowed for a change in the treatment paradigm of aortic arch pathology, moving from open surgical repair to hybrid procedures and exclusively endovascular treatment. Conventional total aortic arch replacement, first described in the fifties,1 remains among the most
1 Angiology and Vascular Surgery Department, Centro Hospitalar do Porto, Oporto, Portugal. 2 ICVE - Instituto de Cirurgia Vascular e Endovascular de S~ao Paulo, S~ ao Paulo, Brazil.
Correspondence to: Gabriela Teixeira, Hospital de Santo Antonio, Centro Hospitalar do Porto, Largo do Prof. Abel Salazar, 4099-001 Porto, Portugal; E-mail: [email protected] Ann Vasc Surg 2019; -: 1.e1–1.e4 https://doi.org/10.1016/j.avsg.2019.07.015 Ó 2019 Elsevier Inc. All rights reserved. Manuscript received: April 27, 2019; manuscript accepted: July 29, 2019; published online: - - -
challenging and complex cardiovascular surgeries. Often requiring a cardiopulmonary bypass and a period of profound hypothermia and circulatory arrest, this procedure carries a considerable rate of morbidity and mortality. Despite higher standards of perioperative care, advances in operative techniques, and the use of protective adjuncts, the associated morbidity is significant. In a recent retrospective report of ascending aorta and arch repair, from the American Society of Thoracic Surgeons database, a mortality and a stroke rate of 12% each were documented.2 Hybrid arch repair with supra-aortic debranching and endografting into the ascending aorta, first described by Buth,3 is a less-invasive method as there is no need for deep hypothermic cardiac arrest. However, an off-pump ascending side clamping through a median sternotomy is required for zone 0 case to perform the debranching of the supraaortic vessels, and it is usually associated with multiple procedures. The morbidity and early mortality 1.e1
1.e2 Case Report
rates were found to be comparable with those of open arch replacement.4 The introduction of fenestrated and branched stent grafts (Inoue5 and Chuter6) enabled minimally invasive repair of the aortic arch. However, the price and time of manufacture remain the 2 main barriers to their widespread use. In 2007, Criado7 extended the application of chimney grafts for partial aortic arch repair (zone 1 or 2). Later, Lobato broke new barriers and reported a total endovascular aortic arch replacement (zone 0) with the sandwich technique, proving it safe and feasible.8 In the chimney (or snorkel) technique, the cover stent is positioned between the aortic wall and the stent graft in an anterograde flow. In the sandwich technique, the cover stent is positioned between the 2 stents grafts e it means that the cover stent does not have contact with the aortic wall. The opposite flow directionality of the conduit distinguishes the periscope technique, in which the cover stent is positioned between the aortic wall and the stent graft in a retrograde flow. In the sandwich periscope, the cover stent is also in a retrograde flow but positioned between the 2 stents grafts. Our patient presented with a type I endoleak and an enlarging and symptomatic descending thoracic aortic aneurysm. He had been treated with thoracic endovascular aortic repair (TEVAR), 2 years ago, for descending thoracic aortic aneurysm complicating a chronic type B aortic dissection. We successfully performed total endovascular zone 0 replacement of the aortic arch with the chimney/periscope/sandwich techniques. The significant increase in neck length enabled successful endograft fixation and seal, without type I endoleak, and excluded the aneurysm.
CASE REPORT A 49-year-old male patient with chronic type B aortic dissection (TBAD) with descending thoracic aortic aneurysm was admitted with thoracic pain. Previous medical history includes HIV seropositive and hypertension under control with 3 medications. The patient had been submitted to an unsuccessful TEVAR for a complicated TBAD, 2 years ago, in another service. The descending aortic diameter at first diagnosis was 59 mm and a thoracic stent graft was placed immediately after the ostia of the left subclavian artery (LSA) (TX2Ò). This procedure complicated with type I endoleak and a sac expansion of 100 mm after 2 years. The admission angioecomputed tomography (CT) revealed type Ia and Ib endoleaks and partial false lumen thrombosis (Figs. 1 and 2). The patient was admitted for aneurysm repair in an urgent setting and was proposed to a total endovascular zone
Annals of Vascular Surgery
Fig. 1. Preoperative computed tomography 3D reconstruction from the anterolateral view. 0 aortic arch replacement with chimney/periscope/sandwich techniques: 1) Extend TEVAR distally to ensure ‘‘healthy’’ runoff; 2) Left subclavian artery endorevascularization with periscope sandwich technique; 3) Endorevascularization of brachiocephalic trunk and left carotid with parallel chimney graft technique; 4) Extend TEVAR proximally to zone 0. The procedure was performed under general anesthesia. Patient preparation included antibiotic prophylaxis, urinary catheter placement, central venous access, arterial line, and temporary pacemaker implantation. Right femoral, both axillary, and left common carotid arteries were surgically exposed, with proximal and distal control, and a percutaneous access of left femoral artery was performed. Aortic access was obtained, and a stiff guidewire was positioned on the outer curvature of the arch through the right common femoral artery and a diagnostic pigtail catheter was placed in the ascending aorta, through the left common femoral artery. Three 12F introducers were positioned through both axillary and left common carotid artery. A thoracic stent graft (GoreÒ C-TAGÒ 34 100 mm) was advanced through the right femoral artery access and deployed with the proximal end just below the LSA origin (Fig. 3A). Then, we introduced a second thoracic stent graft (Gore C-TAG 40 200 mm) and left it in position for delivery with the proximal end just above the coronary artery ostia, where the sealing zone diameter was 34 mm (20% endograft oversizing). We positioned 2 ViabahnÒ grafts (13 100 mm and 8 100 mm) through
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1.e3
Fig. 2. Preoperative axial computed tomography showing proximal endoleak (la) and maximum diameter.
Fig. 3. Intraprocedural angiogram after deployment of first thoracic stent graft below LSA (A) and after second stent graft and covered stents deployment (B).
right brachiocephalic and left common carotid arteries, respectively, in a retrograde fashion, with the distal tip close to the sinutubular junction. The third Viabahn graft (13 100 mm) into the LSA, with the distal tip into the thoracic aorta (periscope fashion). Then, we deployed and accommodated the thoracic stent graft using a latex balloon (Gore Tri-Lobe Balloon Catheter). Finally, we deployed the 3 covered stents (Fig. 3B). During the procedure, rapid ventricular pacing was performed during C-TAG deployment and Tri-lobe balloon accommodation. The femoral, axillary, and left carotid arteries were closed in a primary fashion. The procedure time was 180 min. The patient was extubated on the day of the operation, and the perioperative period was uneventful. The distal perfusion was adequate with palpable pedal pulses. There were no neurological deficits and no need for spinal drain e we consider only elective cerebrospinal fluid drainage postoperatively because spinal cord injury is an uncommon complication with the sandwich technique.8
A 1-month (Fig. 4) and 12-month angio-CT demonstrated successful endograft fixation and seal with no endoleaks; all branches were patent, and the aneurysm was excluded.
DISCUSSION The concept of endoluminal exclusion of an aortic aneurysm was a revolution in the management of patients with aortic disease, resulting in a minimally invasive procedure, with a significant reduction in perioperative morbidity and mortality compared with conventional open surgical repair. Owing to the complexity of aortic arch anatomy with its major branches, repairing aortic arch pathology remains a challenge for endovascular technology and it may be not technically feasible for everyone. Major concerns should be addressed to avoid longer cerebral ischemia time, embolization, arm ischemia, and
1.e4 Case Report
Annals of Vascular Surgery
cardiothoracic department, for whom the urgent setting and the HIV seropositive condition may have influenced their decision. Evidence has been given that the sandwich technique is safe and effective in aneurysm exclusion and target vessel revascularization for aortic arch aneurysms, especially being useful in patients with multiple comorbidities whose outcome in open surgery is usually poor or in urgent cases when fenestrated repair is unfeasible.
CONCLUSION Over the past years, technical development of endovascular intervention has undoubtedly made the treatment of an ever-growing percentage of patients possible, including those at high surgical risk and not previously considered surgical candidates. In this article, we documented a successful case report of total endovascular arch replacement. We want to highlight that a detailed procedure planning and a close follow-up are crucial to ensure the best possible outcome. REFERENCES Fig. 4. Thirty-day follow-up computed tomography. 3D reconstruction of the aorta with aneurism exclusion and all target arteries patent.
paraplegia and to ensure perfect endoprosthesis liberation and target vessel patency. A detailed study of the patient’s anatomy and operative strategy, the endovascular expertise and experience, and the right choice of material are critical measures for success. The decision to treat young patients with endovascular repair still remains controversial, as we cannot predict the long-term behavior of this endoprosthesis. Exciting short-term results have been published; however, long-term results are still lacking. Our department is of vascular and endovascular surgery, and this patient was referred to us by the
1. DeBakey ME, Crawford ES, Cooley DA, et al. Successful resection of fusiform aneurysm of aortic arch with replacement by homograft. Surg Gynecol Obstet 1957;105:657e64. 2. Patel HJ, Deeb GM. Open aortic arch reconstruction. Ann Cardiothorac Surg 2013;2:181e3. 3. Buth J, Penn O, Tielbeek A, et al. Combined approach to stent-graft treatment of an aortic arch aneurysm. J Endovasc Surg 1998;5:329e32. 4. Rudarakanchana N, Jenkins MP. Hybrid and total endovascular repair of the aortic arch. Br J Surg 2018;105:315e27. 5. Inoue K, Hosokawa H, Iwase T, et al. Aortic arch reconstruction by transluminally placed endovascular branched stent graft. Circulation 1999;100(19 Suppl):II316e21. 6. Chuter TA, Schneider DB, Reilly LM, et al. Modular branched stent graft for endovascular repair of aortic arch aneurysm and dissection. J Vasc Surg 2003;38:859e63. 7. Criado FJ. Chimney grafts and bare stents: aortic branch preservation revisited. J Endovasc Ther 2007;14:823e4. 8. Lobato AC, Camacho-Lobato L. Endovascular treatment of complex aortic aneurysms using the sandwich technique. J Endovasc Ther 2012;19:691e706.
Traditional open total zone 0 replacement of the aortic arch is one of the most complex, challenging, and demanding operative procedures in cardiovascular surgery, associated with significant morbidity (30e40%) and mortality (8e20%). Total endovascular zone 0 replacement of the aortic arch with chimney/sandwich techniques as described by Lobato and Camacho-Lobato is a feasible, less invasive, less demanding, and time-consuming option to hybrid and/or traditional open replacement of the aortic arch, particularly in the urgent/emergent settings. We are reporting a case of a 49-year-old patient with chronic type B aortic dissection complicated with descending thoracic aortic aneurysm and an unsuccessful zone 3 thoracic endovascular aortic repair, complicated with type Ia endoleak. He presented with an enlarging and symptomatic descending thoracic aortic aneurysm. An extended proximal (to the zone 0) and distal thoracic endovascular aortic repair was performed to ensure appropriate proximal and distal landing zones (C-TAG). Left subclavian artery endorevascularization was undertaken with periscope sandwich technique (Viabahn), while brachiocephalic trunk and left carotid artery endorevascularizations were carried on with the chimney graft technique (Viabahn). The procedure was uneventful and the one-month and one-year follow-up angioecomputed tomography revealed no endoleaks, patency of all branches, and exclusion of the aneurysm.
The treatment of patients with large aneurysms of the aortic arch often represents a challenge due to the complexity of the procedure. Advances in endovascular technology has allowed for a change in the treatment paradigm of aortic arch pathology, moving from open surgical repair to hybrid procedures and exclusively endovascular treatment. Conventional total aortic arch replacement, first described in the fifties,1 remains among the most
1 Angiology and Vascular Surgery Department, Centro Hospitalar do Porto, Oporto, Portugal. 2 ICVE - Instituto de Cirurgia Vascular e Endovascular de S~ao Paulo, S~ ao Paulo, Brazil.
Correspondence to: Gabriela Teixeira, Hospital de Santo Antonio, Centro Hospitalar do Porto, Largo do Prof. Abel Salazar, 4099-001 Porto, Portugal; E-mail: [email protected] Ann Vasc Surg 2019; -: 1.e1–1.e4 https://doi.org/10.1016/j.avsg.2019.07.015 Ó 2019 Elsevier Inc. All rights reserved. Manuscript received: April 27, 2019; manuscript accepted: July 29, 2019; published online: - - -
challenging and complex cardiovascular surgeries. Often requiring a cardiopulmonary bypass and a period of profound hypothermia and circulatory arrest, this procedure carries a considerable rate of morbidity and mortality. Despite higher standards of perioperative care, advances in operative techniques, and the use of protective adjuncts, the associated morbidity is significant. In a recent retrospective report of ascending aorta and arch repair, from the American Society of Thoracic Surgeons database, a mortality and a stroke rate of 12% each were documented.2 Hybrid arch repair with supra-aortic debranching and endografting into the ascending aorta, first described by Buth,3 is a less-invasive method as there is no need for deep hypothermic cardiac arrest. However, an off-pump ascending side clamping through a median sternotomy is required for zone 0 case to perform the debranching of the supraaortic vessels, and it is usually associated with multiple procedures. The morbidity and early mortality 1.e1
1.e2 Case Report
rates were found to be comparable with those of open arch replacement.4 The introduction of fenestrated and branched stent grafts (Inoue5 and Chuter6) enabled minimally invasive repair of the aortic arch. However, the price and time of manufacture remain the 2 main barriers to their widespread use. In 2007, Criado7 extended the application of chimney grafts for partial aortic arch repair (zone 1 or 2). Later, Lobato broke new barriers and reported a total endovascular aortic arch replacement (zone 0) with the sandwich technique, proving it safe and feasible.8 In the chimney (or snorkel) technique, the cover stent is positioned between the aortic wall and the stent graft in an anterograde flow. In the sandwich technique, the cover stent is positioned between the 2 stents grafts e it means that the cover stent does not have contact with the aortic wall. The opposite flow directionality of the conduit distinguishes the periscope technique, in which the cover stent is positioned between the aortic wall and the stent graft in a retrograde flow. In the sandwich periscope, the cover stent is also in a retrograde flow but positioned between the 2 stents grafts. Our patient presented with a type I endoleak and an enlarging and symptomatic descending thoracic aortic aneurysm. He had been treated with thoracic endovascular aortic repair (TEVAR), 2 years ago, for descending thoracic aortic aneurysm complicating a chronic type B aortic dissection. We successfully performed total endovascular zone 0 replacement of the aortic arch with the chimney/periscope/sandwich techniques. The significant increase in neck length enabled successful endograft fixation and seal, without type I endoleak, and excluded the aneurysm.
CASE REPORT A 49-year-old male patient with chronic type B aortic dissection (TBAD) with descending thoracic aortic aneurysm was admitted with thoracic pain. Previous medical history includes HIV seropositive and hypertension under control with 3 medications. The patient had been submitted to an unsuccessful TEVAR for a complicated TBAD, 2 years ago, in another service. The descending aortic diameter at first diagnosis was 59 mm and a thoracic stent graft was placed immediately after the ostia of the left subclavian artery (LSA) (TX2Ò). This procedure complicated with type I endoleak and a sac expansion of 100 mm after 2 years. The admission angioecomputed tomography (CT) revealed type Ia and Ib endoleaks and partial false lumen thrombosis (Figs. 1 and 2). The patient was admitted for aneurysm repair in an urgent setting and was proposed to a total endovascular zone
Annals of Vascular Surgery
Fig. 1. Preoperative computed tomography 3D reconstruction from the anterolateral view. 0 aortic arch replacement with chimney/periscope/sandwich techniques: 1) Extend TEVAR distally to ensure ‘‘healthy’’ runoff; 2) Left subclavian artery endorevascularization with periscope sandwich technique; 3) Endorevascularization of brachiocephalic trunk and left carotid with parallel chimney graft technique; 4) Extend TEVAR proximally to zone 0. The procedure was performed under general anesthesia. Patient preparation included antibiotic prophylaxis, urinary catheter placement, central venous access, arterial line, and temporary pacemaker implantation. Right femoral, both axillary, and left common carotid arteries were surgically exposed, with proximal and distal control, and a percutaneous access of left femoral artery was performed. Aortic access was obtained, and a stiff guidewire was positioned on the outer curvature of the arch through the right common femoral artery and a diagnostic pigtail catheter was placed in the ascending aorta, through the left common femoral artery. Three 12F introducers were positioned through both axillary and left common carotid artery. A thoracic stent graft (GoreÒ C-TAGÒ 34 100 mm) was advanced through the right femoral artery access and deployed with the proximal end just below the LSA origin (Fig. 3A). Then, we introduced a second thoracic stent graft (Gore C-TAG 40 200 mm) and left it in position for delivery with the proximal end just above the coronary artery ostia, where the sealing zone diameter was 34 mm (20% endograft oversizing). We positioned 2 ViabahnÒ grafts (13 100 mm and 8 100 mm) through
Volume
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2019
Case Report
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Fig. 2. Preoperative axial computed tomography showing proximal endoleak (la) and maximum diameter.
Fig. 3. Intraprocedural angiogram after deployment of first thoracic stent graft below LSA (A) and after second stent graft and covered stents deployment (B).
right brachiocephalic and left common carotid arteries, respectively, in a retrograde fashion, with the distal tip close to the sinutubular junction. The third Viabahn graft (13 100 mm) into the LSA, with the distal tip into the thoracic aorta (periscope fashion). Then, we deployed and accommodated the thoracic stent graft using a latex balloon (Gore Tri-Lobe Balloon Catheter). Finally, we deployed the 3 covered stents (Fig. 3B). During the procedure, rapid ventricular pacing was performed during C-TAG deployment and Tri-lobe balloon accommodation. The femoral, axillary, and left carotid arteries were closed in a primary fashion. The procedure time was 180 min. The patient was extubated on the day of the operation, and the perioperative period was uneventful. The distal perfusion was adequate with palpable pedal pulses. There were no neurological deficits and no need for spinal drain e we consider only elective cerebrospinal fluid drainage postoperatively because spinal cord injury is an uncommon complication with the sandwich technique.8
A 1-month (Fig. 4) and 12-month angio-CT demonstrated successful endograft fixation and seal with no endoleaks; all branches were patent, and the aneurysm was excluded.
DISCUSSION The concept of endoluminal exclusion of an aortic aneurysm was a revolution in the management of patients with aortic disease, resulting in a minimally invasive procedure, with a significant reduction in perioperative morbidity and mortality compared with conventional open surgical repair. Owing to the complexity of aortic arch anatomy with its major branches, repairing aortic arch pathology remains a challenge for endovascular technology and it may be not technically feasible for everyone. Major concerns should be addressed to avoid longer cerebral ischemia time, embolization, arm ischemia, and
1.e4 Case Report
Annals of Vascular Surgery
cardiothoracic department, for whom the urgent setting and the HIV seropositive condition may have influenced their decision. Evidence has been given that the sandwich technique is safe and effective in aneurysm exclusion and target vessel revascularization for aortic arch aneurysms, especially being useful in patients with multiple comorbidities whose outcome in open surgery is usually poor or in urgent cases when fenestrated repair is unfeasible.
CONCLUSION Over the past years, technical development of endovascular intervention has undoubtedly made the treatment of an ever-growing percentage of patients possible, including those at high surgical risk and not previously considered surgical candidates. In this article, we documented a successful case report of total endovascular arch replacement. We want to highlight that a detailed procedure planning and a close follow-up are crucial to ensure the best possible outcome. REFERENCES Fig. 4. Thirty-day follow-up computed tomography. 3D reconstruction of the aorta with aneurism exclusion and all target arteries patent.
paraplegia and to ensure perfect endoprosthesis liberation and target vessel patency. A detailed study of the patient’s anatomy and operative strategy, the endovascular expertise and experience, and the right choice of material are critical measures for success. The decision to treat young patients with endovascular repair still remains controversial, as we cannot predict the long-term behavior of this endoprosthesis. Exciting short-term results have been published; however, long-term results are still lacking. Our department is of vascular and endovascular surgery, and this patient was referred to us by the
1. DeBakey ME, Crawford ES, Cooley DA, et al. Successful resection of fusiform aneurysm of aortic arch with replacement by homograft. Surg Gynecol Obstet 1957;105:657e64. 2. Patel HJ, Deeb GM. Open aortic arch reconstruction. Ann Cardiothorac Surg 2013;2:181e3. 3. Buth J, Penn O, Tielbeek A, et al. Combined approach to stent-graft treatment of an aortic arch aneurysm. J Endovasc Surg 1998;5:329e32. 4. Rudarakanchana N, Jenkins MP. Hybrid and total endovascular repair of the aortic arch. Br J Surg 2018;105:315e27. 5. Inoue K, Hosokawa H, Iwase T, et al. Aortic arch reconstruction by transluminally placed endovascular branched stent graft. Circulation 1999;100(19 Suppl):II316e21. 6. Chuter TA, Schneider DB, Reilly LM, et al. Modular branched stent graft for endovascular repair of aortic arch aneurysm and dissection. J Vasc Surg 2003;38:859e63. 7. Criado FJ. Chimney grafts and bare stents: aortic branch preservation revisited. J Endovasc Ther 2007;14:823e4. 8. Lobato AC, Camacho-Lobato L. Endovascular treatment of complex aortic aneurysms using the sandwich technique. J Endovasc Ther 2012;19:691e706.