- Email: [email protected]
Total Endovascular Arch Repair Using Needle Fenestration and Extracorporeal Membrane Oxygenation
Accepted Manuscript Total Endovascular Arch Repair Using Needle Fenestration and Extracorporeal Membrane Oxygenation Kyle W. Eudailey, MD, Gregory Von Mering, MD, Paxton Johanson, James English, Clifton T. Lewis, MD, Mustafa I. Ahmed, MD PII:
S0003-4975(19)31025-2
DOI:
https://doi.org/10.1016/j.athoracsur.2019.05.064
Reference:
ATS 32807
To appear in:
The Annals of Thoracic Surgery
Received Date: 7 March 2019 Revised Date:
15 May 2019
Accepted Date: 18 May 2019
Please cite this article as: Eudailey KW, Von Mering G, Johanson P, English J, Lewis CT, Ahmed MI, Total Endovascular Arch Repair Using Needle Fenestration and Extracorporeal Membrane Oxygenation, The Annals of Thoracic Surgery (2019), doi: https://doi.org/10.1016/j.athoracsur.2019.05.064. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Total Endovascular Arch Repair Using Needle Fenestration and Extracorporeal Membrane Oxygenation
RI PT
Running Head: Total Endo Arch with Needle Fenestration
Kyle W. Eudailey MD1, Gregory Von Mering MD2, Paxton Johanson1, James English1, Clifton
SC
T. Lewis MD1, Mustafa I. Ahmed MD2.
Division of Cardiothoracic Surgery, University of Alabama Birmingham, Birmingham, AL1
Kyle W. Eudailey, MD
TE D
Address for correspondence:
M AN U
Division of Cardiology, University of Alabama Birmingham, Birmingham, AL2
Division of Cardiothoracic Surgery
EP
University of Alabama Birmingham 619 19th Street South
AC C
Birmingham 35249
Email: [email protected]
ACCEPTED MANUSCRIPT
Abstract There remains a clinical need for endovascular repair of the ascending aorta and the aortic arch in patients who are prohibitively high risk for open surgical repair. Herein we present a case of a
RI PT
total endovascular arch repair using a novel technique for graft fenestration using a trans-septal needle with extracorporeal membrane oxygenation (ECMO) support. While there have been publications describing the use of trans-septal needle fenestration use in endovascular stenting
SC
[1,2], there has been no prior publication discussing the use in arch fenestrations. We present this case as an example of techniques that may be useful in the expanding landscape of endovascular
AC C
EP
TE D
M AN U
ascending and arch repair.
ACCEPTED MANUSCRIPT
There remains a clinical need for endovascular repair of the ascending aorta and the aortic arch in patients who are prohibitively high risk for open surgical repair. Herein we present a case of a total endovascular arch repair using a novel technique for graft fenestration using a trans-septal
RI PT
needle with extracorporeal membrane oxygenation (ECMO) support. While there have been publications describing the use of trans-septal needle fenestration use in endovascular stenting [1,2], there has been no prior publication discussing the use in arch fenestrations. We present this
SC
case as an example of techniques that may be useful in the expanding landscape of endovascular
M AN U
ascending and arch repair.
This is a case of a 64-year-old man with a transverse arch aneurysm of 7.2cm at greatest diameter who was symptomatic with recurrent episodes of syncope and back pain. The patient had a history of a prior Type A dissection 2 years prior, at which point he underwent a hemi-arch
TE D
repair. Additional comorbidities included coronary artery disease status post multiple prior percutaneous coronary interventions and systolic heart failure. At the time of his presentation to our institution, he was on hospice care and deemed inoperable by multiple surgical evaluations
EP
secondary to his depressed ejection fraction and frailty. A long discussion with the patient was had regarding investigational usage of endografts for treatment of his aneurysm, and ultimately
AC C
the patient wished to proceed.
3D reconstruction of a cardiac gated computer tomography angiography (CTA) was used for careful preoperative case planning (Figure 1). Patient was taken to the hybrid operating room for total endovascular arch repair with ECMO support. The operative plan consisted of left carotid to left subclavian bypass, veno-arterial ECMO initiation with inflow via right femoral vein and outflow via the right and left common carotid arteries, complete exclusion of the great vessels
ACCEPTED MANUSCRIPT
with an endograft extending from the ascending to the mid descending thoracic aorta, retrograde fenestration and stenting of the brachiocephalic and left carotid, and finally plugging of the origin of the left subclavian.
RI PT
Surgical exposure was acquired prior to heparinization through 5cm left supraclavicular incision for the left carotid and left subclavian, 3cm suprasternal incision for the base of the right carotid, a 3cm right groin exposure, as well as percutaneous left brachial artery and left femoral vein.
SC
First a 7mm ringed PTFE graft (Gore, Newark, DE) was used to perform a standard carotid
subclavian bypass. Next, we established our access for retrograde fenestration and antegrade
M AN U
ECMO arterial flow in both carotids. Braided 6F catheters we placed in the proximal portion of both the left and right common carotid oriented in a retrograde fashion back towards the arch. An additional set of braided 8F catheters were placed in distal portion of both the left and right common carotid arteries oriented in an antegrade fashion. These distal antegrade 8F sheaths were
TE D
subsequently Y-ed together, de-aired, and connected to the arterial limb of our ECMO circuit. Right axillary arterial cannulation for ECMO is an alternative cannulation strategy, but we opted to avoid an additional incision. Next a 25F multiport venous cannula was placed in the right
EP
femoral vein and trans esophageal echocardiography (TEE) was used to confirm placement. ECMO was subsequently initiated with low flows of 600cc to 1000cc per minute and non-
AC C
invasive cerebral saturations were monitored . A double curved Lunderquist extra stiff wire (Cook Medical, Bloomington, IN) was seated at the apex of the ventricle and our graft delivery system was advanced to the aortic arch. Intravascular Ultrasound (IVUS) was performed to confirm true lumen for the entirety Lunderquist wire course and to confirm anatomy and measurements. Based on preop CTA, initial aortogram (Figure 2a), and IVUS, a 46mmx46mmx200mm ValiantTM stent graft (Medtronic, Dublin, Ireland) was chosen and using
ACCEPTED MANUSCRIPT
rapid pacing was deployed just above the Sino-tubular junction with purposeful covering of head vessels. No change in head saturations were noted as the patient maintained adequate ECMO flows and perfusion. Two additional grafts were deployed for complete exclusion of the arch
RI PT
aneurysm, a tapered 46mmx42mmx150mm ValiantTM graft and a 42mmx38mmx150mm
ValiantTM graft (Figure 2b). We proceeded with direct fenestration of the arch graft using a
BRK-1TM trans-septal needle (St Jude Medical, St Paul, MN). Using the left carotid sheath, a
SC
BRK-1TM needle was passed through an SL-1 sheath (St Jude Medical, St Paul, MN). The needle was confirmed to be on graft by feel and was checked in orthogonal views to confirm positioning
M AN U
(Figure 2c). The graft was punctured, the needle removed, and a 0.025” ProTrackTM Pigtail Wire (Baylis Medical Company, Mississauga, ON) wire was advanced to the ascending aorta. This tract was then dilated with a 6mm balloon, and an 11mm x59mm VBX stent (Gore, Newark, DE) was deployed and post dilated. This was process was repeated for fenestration of the
TE D
brachiocephalic, using a 11mmx39mm Gore VBX stent followed by an extension with a 11mmx59mm VBX stent and further post dilation. Completion angiography showed excellent flow in the arch vessels with no endoleaks. A 16mm AmplatzerTM vascular plug (St Jude
EP
Medical, St Paul, MN) was placed through the left brachial sheath at the subclavian origin. A final digital subtraction angiography of the arch confirmed no endoleaks and exclusion of the left
AC C
subclavian origin with excellent filling of the left vertebral artery as well (Figure 2d). Post-operatively the patient did well, he was extubated immediately after the procedure. A repeat CTA was performed on POD6 which showed excellent exclusion of his arch aneurysm, flow into all head vessels, and no endoleaks (Figure 3).
Comment
ACCEPTED MANUSCRIPT
At present the technology available for complex endovascular arch intervention and fenestration is limited. We believe this to be a simple modification to commercially available devices, and believe that this technique is safe, effective, and reproducible for endovascular arch repair in
RI PT
high risk patients. Benefits if this technique include ease of use, reproducibility, availability, and cost. Notable limitationsinclude the force that is needed to puncture the graft. This is possible for an arch fenestration with a good proximal landing zone such as a prior graft in this case, but
SC
likely would be harder to execute for subclavian fenestration with a short proximal landing zone, as the proximal graft may not have the proper counter force. Other described fenestration
M AN U
techniques include radiofrequency [3], standard needle [4], and laser [5]. Radiofrequency and laser techniques use energy sources to perforate the graft. Laser is the most well studied at present, but there remain unknowns about the long-term durability of a laser fenestration in arch grafts. In addition, the laser device itself is costly. The possible benefit of this technique may be
TE D
reduced trauma to the graft and limited endoleaks. The ideal solution for these patients will be the development of reliable multi-branch devices, but we are still several years away from that
AC C
EP
technology being commercially available in the United States.
ACCEPTED MANUSCRIPT
References: [1] Kolbel T, Carpenter S, Diener H, Wipper S, Debus E, Larena-Avellaneda A. Antegrade In
EVAR. J Endovasc Ther. 2013. 20(3), 289-294.
RI PT
Situ Stent-Graft Fenestration for the Renal Artery Following Inadvertent Coverage During
[2] Gloion M, Coscas R, McWilliams RG, Javerliat I, Goeau-Brissonnie O, Coggia M. A
Endovascular Surgery. Dec 2016. 52(6). 787-800.
SC
comprehensive review of in situ fenestration of aortic endografts. Eur J of Vascular and
[3] Tse LW, Lindsay TF, Roche Nagle G, Oreopoulos GD, Ouzounian M, Tan
M AN U
KT. Radiofrequency in situ fenestration for aortic arch vessels during thoracic endovascular repair. J Endovasc Ther. 2015. 22. 116–121.
[4] Katada Y, Kondo S, Tsuboi E, Rokkaku K, Irie Y, Yokoyama H. Endovascular total arch repair using in situ fenestration for arch aneurysm and chronic type A dissection. Ann Thorac
TE D
Surg. 2016. 101:625–630.
[5] Qin, J., Zhao, Z., Wang, R., Ye, K., Li, W., Liu, X., Liu, G., Cui, C., Shi, H., Peng, Z., Yuan, F., Yang, X., Lu, M., Huang, X., Jiang, M., Wang, X., Yin, M., … Lu, X. (2017). In Situ Laser
EP
Fenestration Is a Feasible Method for Revascularization of Aortic Arch During Thoracic Endovascular Aortic Repair. Journal of the American Heart Association. 2017 6(4), e004542.
AC C
doi:10.1161/JAHA.116.004542
ACCEPTED MANUSCRIPT
Figure Legends Figure 1. Preop 3D CTA reconstruction. Figure 2. a.) Initial DSA aortogram. b.) DSA aortogram following initial graft deployment,
RI PT
demonstrating exclusion of the arch aneurysm and the head vessels. c.) Steep ROA, orthogonal view fluoroscopy confirming trans-septal needle position. d.) Final DSA aortogram
and left subclavian origin plug.
AC C
EP
TE D
M AN U
Figure 3. Postop 3D CTA Reconstruction.
SC
demonstrating fenestration of brachiocephalic and left carotid, left carotid-subclavian bypass,
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
S0003-4975(19)31025-2
DOI:
https://doi.org/10.1016/j.athoracsur.2019.05.064
Reference:
ATS 32807
To appear in:
The Annals of Thoracic Surgery
Received Date: 7 March 2019 Revised Date:
15 May 2019
Accepted Date: 18 May 2019
Please cite this article as: Eudailey KW, Von Mering G, Johanson P, English J, Lewis CT, Ahmed MI, Total Endovascular Arch Repair Using Needle Fenestration and Extracorporeal Membrane Oxygenation, The Annals of Thoracic Surgery (2019), doi: https://doi.org/10.1016/j.athoracsur.2019.05.064. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Total Endovascular Arch Repair Using Needle Fenestration and Extracorporeal Membrane Oxygenation
RI PT
Running Head: Total Endo Arch with Needle Fenestration
Kyle W. Eudailey MD1, Gregory Von Mering MD2, Paxton Johanson1, James English1, Clifton
SC
T. Lewis MD1, Mustafa I. Ahmed MD2.
Division of Cardiothoracic Surgery, University of Alabama Birmingham, Birmingham, AL1
Kyle W. Eudailey, MD
TE D
Address for correspondence:
M AN U
Division of Cardiology, University of Alabama Birmingham, Birmingham, AL2
Division of Cardiothoracic Surgery
EP
University of Alabama Birmingham 619 19th Street South
AC C
Birmingham 35249
Email: [email protected]
ACCEPTED MANUSCRIPT
Abstract There remains a clinical need for endovascular repair of the ascending aorta and the aortic arch in patients who are prohibitively high risk for open surgical repair. Herein we present a case of a
RI PT
total endovascular arch repair using a novel technique for graft fenestration using a trans-septal needle with extracorporeal membrane oxygenation (ECMO) support. While there have been publications describing the use of trans-septal needle fenestration use in endovascular stenting
SC
[1,2], there has been no prior publication discussing the use in arch fenestrations. We present this case as an example of techniques that may be useful in the expanding landscape of endovascular
AC C
EP
TE D
M AN U
ascending and arch repair.
ACCEPTED MANUSCRIPT
There remains a clinical need for endovascular repair of the ascending aorta and the aortic arch in patients who are prohibitively high risk for open surgical repair. Herein we present a case of a total endovascular arch repair using a novel technique for graft fenestration using a trans-septal
RI PT
needle with extracorporeal membrane oxygenation (ECMO) support. While there have been publications describing the use of trans-septal needle fenestration use in endovascular stenting [1,2], there has been no prior publication discussing the use in arch fenestrations. We present this
SC
case as an example of techniques that may be useful in the expanding landscape of endovascular
M AN U
ascending and arch repair.
This is a case of a 64-year-old man with a transverse arch aneurysm of 7.2cm at greatest diameter who was symptomatic with recurrent episodes of syncope and back pain. The patient had a history of a prior Type A dissection 2 years prior, at which point he underwent a hemi-arch
TE D
repair. Additional comorbidities included coronary artery disease status post multiple prior percutaneous coronary interventions and systolic heart failure. At the time of his presentation to our institution, he was on hospice care and deemed inoperable by multiple surgical evaluations
EP
secondary to his depressed ejection fraction and frailty. A long discussion with the patient was had regarding investigational usage of endografts for treatment of his aneurysm, and ultimately
AC C
the patient wished to proceed.
3D reconstruction of a cardiac gated computer tomography angiography (CTA) was used for careful preoperative case planning (Figure 1). Patient was taken to the hybrid operating room for total endovascular arch repair with ECMO support. The operative plan consisted of left carotid to left subclavian bypass, veno-arterial ECMO initiation with inflow via right femoral vein and outflow via the right and left common carotid arteries, complete exclusion of the great vessels
ACCEPTED MANUSCRIPT
with an endograft extending from the ascending to the mid descending thoracic aorta, retrograde fenestration and stenting of the brachiocephalic and left carotid, and finally plugging of the origin of the left subclavian.
RI PT
Surgical exposure was acquired prior to heparinization through 5cm left supraclavicular incision for the left carotid and left subclavian, 3cm suprasternal incision for the base of the right carotid, a 3cm right groin exposure, as well as percutaneous left brachial artery and left femoral vein.
SC
First a 7mm ringed PTFE graft (Gore, Newark, DE) was used to perform a standard carotid
subclavian bypass. Next, we established our access for retrograde fenestration and antegrade
M AN U
ECMO arterial flow in both carotids. Braided 6F catheters we placed in the proximal portion of both the left and right common carotid oriented in a retrograde fashion back towards the arch. An additional set of braided 8F catheters were placed in distal portion of both the left and right common carotid arteries oriented in an antegrade fashion. These distal antegrade 8F sheaths were
TE D
subsequently Y-ed together, de-aired, and connected to the arterial limb of our ECMO circuit. Right axillary arterial cannulation for ECMO is an alternative cannulation strategy, but we opted to avoid an additional incision. Next a 25F multiport venous cannula was placed in the right
EP
femoral vein and trans esophageal echocardiography (TEE) was used to confirm placement. ECMO was subsequently initiated with low flows of 600cc to 1000cc per minute and non-
AC C
invasive cerebral saturations were monitored . A double curved Lunderquist extra stiff wire (Cook Medical, Bloomington, IN) was seated at the apex of the ventricle and our graft delivery system was advanced to the aortic arch. Intravascular Ultrasound (IVUS) was performed to confirm true lumen for the entirety Lunderquist wire course and to confirm anatomy and measurements. Based on preop CTA, initial aortogram (Figure 2a), and IVUS, a 46mmx46mmx200mm ValiantTM stent graft (Medtronic, Dublin, Ireland) was chosen and using
ACCEPTED MANUSCRIPT
rapid pacing was deployed just above the Sino-tubular junction with purposeful covering of head vessels. No change in head saturations were noted as the patient maintained adequate ECMO flows and perfusion. Two additional grafts were deployed for complete exclusion of the arch
RI PT
aneurysm, a tapered 46mmx42mmx150mm ValiantTM graft and a 42mmx38mmx150mm
ValiantTM graft (Figure 2b). We proceeded with direct fenestration of the arch graft using a
BRK-1TM trans-septal needle (St Jude Medical, St Paul, MN). Using the left carotid sheath, a
SC
BRK-1TM needle was passed through an SL-1 sheath (St Jude Medical, St Paul, MN). The needle was confirmed to be on graft by feel and was checked in orthogonal views to confirm positioning
M AN U
(Figure 2c). The graft was punctured, the needle removed, and a 0.025” ProTrackTM Pigtail Wire (Baylis Medical Company, Mississauga, ON) wire was advanced to the ascending aorta. This tract was then dilated with a 6mm balloon, and an 11mm x59mm VBX stent (Gore, Newark, DE) was deployed and post dilated. This was process was repeated for fenestration of the
TE D
brachiocephalic, using a 11mmx39mm Gore VBX stent followed by an extension with a 11mmx59mm VBX stent and further post dilation. Completion angiography showed excellent flow in the arch vessels with no endoleaks. A 16mm AmplatzerTM vascular plug (St Jude
EP
Medical, St Paul, MN) was placed through the left brachial sheath at the subclavian origin. A final digital subtraction angiography of the arch confirmed no endoleaks and exclusion of the left
AC C
subclavian origin with excellent filling of the left vertebral artery as well (Figure 2d). Post-operatively the patient did well, he was extubated immediately after the procedure. A repeat CTA was performed on POD6 which showed excellent exclusion of his arch aneurysm, flow into all head vessels, and no endoleaks (Figure 3).
Comment
ACCEPTED MANUSCRIPT
At present the technology available for complex endovascular arch intervention and fenestration is limited. We believe this to be a simple modification to commercially available devices, and believe that this technique is safe, effective, and reproducible for endovascular arch repair in
RI PT
high risk patients. Benefits if this technique include ease of use, reproducibility, availability, and cost. Notable limitationsinclude the force that is needed to puncture the graft. This is possible for an arch fenestration with a good proximal landing zone such as a prior graft in this case, but
SC
likely would be harder to execute for subclavian fenestration with a short proximal landing zone, as the proximal graft may not have the proper counter force. Other described fenestration
M AN U
techniques include radiofrequency [3], standard needle [4], and laser [5]. Radiofrequency and laser techniques use energy sources to perforate the graft. Laser is the most well studied at present, but there remain unknowns about the long-term durability of a laser fenestration in arch grafts. In addition, the laser device itself is costly. The possible benefit of this technique may be
TE D
reduced trauma to the graft and limited endoleaks. The ideal solution for these patients will be the development of reliable multi-branch devices, but we are still several years away from that
AC C
EP
technology being commercially available in the United States.
ACCEPTED MANUSCRIPT
References: [1] Kolbel T, Carpenter S, Diener H, Wipper S, Debus E, Larena-Avellaneda A. Antegrade In
EVAR. J Endovasc Ther. 2013. 20(3), 289-294.
RI PT
Situ Stent-Graft Fenestration for the Renal Artery Following Inadvertent Coverage During
[2] Gloion M, Coscas R, McWilliams RG, Javerliat I, Goeau-Brissonnie O, Coggia M. A
Endovascular Surgery. Dec 2016. 52(6). 787-800.
SC
comprehensive review of in situ fenestration of aortic endografts. Eur J of Vascular and
[3] Tse LW, Lindsay TF, Roche Nagle G, Oreopoulos GD, Ouzounian M, Tan
M AN U
KT. Radiofrequency in situ fenestration for aortic arch vessels during thoracic endovascular repair. J Endovasc Ther. 2015. 22. 116–121.
[4] Katada Y, Kondo S, Tsuboi E, Rokkaku K, Irie Y, Yokoyama H. Endovascular total arch repair using in situ fenestration for arch aneurysm and chronic type A dissection. Ann Thorac
TE D
Surg. 2016. 101:625–630.
[5] Qin, J., Zhao, Z., Wang, R., Ye, K., Li, W., Liu, X., Liu, G., Cui, C., Shi, H., Peng, Z., Yuan, F., Yang, X., Lu, M., Huang, X., Jiang, M., Wang, X., Yin, M., … Lu, X. (2017). In Situ Laser
EP
Fenestration Is a Feasible Method for Revascularization of Aortic Arch During Thoracic Endovascular Aortic Repair. Journal of the American Heart Association. 2017 6(4), e004542.
AC C
doi:10.1161/JAHA.116.004542
ACCEPTED MANUSCRIPT
Figure Legends Figure 1. Preop 3D CTA reconstruction. Figure 2. a.) Initial DSA aortogram. b.) DSA aortogram following initial graft deployment,
RI PT
demonstrating exclusion of the arch aneurysm and the head vessels. c.) Steep ROA, orthogonal view fluoroscopy confirming trans-septal needle position. d.) Final DSA aortogram
and left subclavian origin plug.
AC C
EP
TE D
M AN U
Figure 3. Postop 3D CTA Reconstruction.
SC
demonstrating fenestration of brachiocephalic and left carotid, left carotid-subclavian bypass,
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT