The strategy of thoracic endovascular repair for aortic arch aneurysms

Thoracic endovascular aneurysm repair (TEVAR) has gained wide acceptance because of its minimal invasiveness and effectiveness for thoracic aortic aneurysms. However, the endovascular technique alone is often not applicable to arch aneurysms due to their anatomical complexity, such as aortic curve and presense of neck branches. The development of branched stent graft that allows total endovascular approach has been slow. Therefore open surgical technique is still needed to obtain an adequate landing zone. Prior total arch replacement with elephant trunk and debranching neck vessels including partial debranching such as carotid-carotid crossover bypass, and total debranching from the ascending aorta were able to create a suitable proximal landing zone. Chimney technique using covered stent for the neck vessels is also effective for arch aneurysms. Here, we report the strategies of TEVAR for aortic arch aneurysms.     

Replacement of the entire thoracic aorta according to the reversed Elephant Trunk technique

The aim of this work is to present our modified Elephant Trunk technique to reduce circulatory arrest time and consequently mortality and morbidity rates. According to Borst's technique the ascending aorta and aortic arch are replaced first, under deep hypothermic circulatory arrest, while a graft segment is left in the descending thoracic aorta. In the second stage of the operation, the descending thoracic aorta is replaced through left thoracotomy using this graft segment. In our modified technique, after the flexion in the proximal segment of the graft, the descending thoracic aorta is replaced first through left thoracotomy in Bio-Pump protection, choosing the best aortic segment for proximal anastomosis. In the second stage we replace the ascending aorta and the aortic arch using the graft and applying Carrel patch anastamosis only to the epiaortic vessels, under deep hypothermic circulatory arrest. It is our opinion that the mortality incidence of this technique is similar to that obtained with Borst's technique, though certainly inferior to the one stage procedure , while the morbidity results are better than those obtained with the Borst Elephant Trunk technique and with the one stage procedure. In fact there are fewer stroke incidents thanks to the reduced times of deep hypothermic circulatory arrest, and fewer postoperative bleedings and respiratory failures thanks to the reduced times of the total cardiopulmonary bypass. At the beginning we used this technique to replace symptomatic aneurysms, covered ruptures, and hematomas of the wall of the descending thoracic aorta, which required replacement of the descending thoracic aorta first; we later extended the treatment to all types of thoracic aorta aneurysms.     

Experiences of intentional carotid stenting in endovascular repair of aortic arch aneurysms--two case reports.

Endovascular repair of thoracic aneurysms has emerged as an attractive alternative especially in patients at high risk. However, the left common carotid artery limits the use of stent-grafts in aneurysms located in the aortic arch or close to the left subclavian artery. We report two cases with aneurysms in the distal arch and proximal descending aorta, where we have used a carotid stent in juxtaposition to an aortic stent-graft, to gain a longer proximal neck in the aortic arch in an attempt not to rely only on a by-pass graft feeding the left carotid artery.     

Early and long-term results of surgery for aortic arch aneurysms using selective cerebral perfusion

OBJECTIVE: We report our operative technique for atherosclerotic arch aneurysms and early and long term results of the surgery. METHODS: Between April 1992 and December 2001, 80 consecutive patients underwent operation for atherosclerotic arch aneurysms. Their mean age was 70 +/- 7 years. Sixty-six (82.5%) patients were operated on electively. All operations were performed under median sternotomy using hypothermic circulatory arrest and selective antegrade cerebral perfusion. Total arch replacement was performed in 66 cases, proximal hemiarch replacement in 4 cases, distal arch replacement using stent graft implantation via aortic arch incision in 8 cases, and patch angioplasty in 2 cases. In 9 of these patients in whom mobile arch atheroma was revealed by intraoperative epiaortic ultrasonography, isolation technique was employed to avoid embolic stroke. RESULTS: Overall in-hospital mortality was 10.0% (8 of 80 patients). Postoperative temporary neurologic dysfunction was 7.5%, and stroke rate was 5.0%. The 3-year, and 5-year actuarial survival rate including hospital death was 79.3% and 75.3% respectively. The 3-year, and 5-year cardiovascular event free survival rate was 68.3% and 60.0% respectively. CONCLUSION: The early and long-term results of surgery for atherosclerotic arch aneurysms were acceptable. Selective cerebral perfusion is an effective brain protective adjunct.     

Fate of aneurysms of the distal arch and proximal descending thoracic aorta after transaortic endovascular Stent-Grafting

BACKGROUND: The purpose of this study was to evaluate the midterm results of transaortic stent-grafting for distal aortic arch aneurysms or proximal descending aortic aneurysms and the feasibility of this method for thoracic aortic aneurysm repair. METHODS: Twenty-three patients with true distal aortic arch aneurysms or proximal descending thoracic aortic aneurysms were repaired with the stent-graft introduced through the incision on the proximal arch aorta. Follow-up computed tomography was performed every 6 months in 21 surviving patients. The maximum dimension of the excluded aneurysmal space and the maximum aneurysmal diameter were measured and evaluated to determine whether the aneurysmal space decreased or disappeared after this alternative procedure. RESULTS: There was 1 hospital death (4.3%) due to cerebral embolism. Another patient died of pneumonia 1 year after surgery. Twenty-one patients (91%) survived during the follow-up period, but 1 patient (4.3%) suffered from paraplegia. The follow-up period ranged from 12 to 62 months (average, 34.3 +/- 15.2). There were no instances of aneurysmal rupture during the follow-up period. Postoperative serial computed tomography scans showed disappearance or significant shrinkage of the excluded aneurysmal space in 20 of 21 patients (95%), except for the one patient with endoluminal leakage. CONCLUSIONS: Transaortic endovascular stent-grafting was an effective alternative approach to treating distal aortic arch aneurysms or proximal descending aortic aneurysms. The excluded aneurysm disappeared or shrunk after successful placement of the stent-graft.     

Combined surgical and endovascular treatment of aortic arch aneurysms

BACKGROUND: Traditional repair of aortic arch aneurysms requires cardiopulmonary bypass, hypothermia, and circulatory arrest and is associated with considerable morbidity and mortality. Endovascular stent-graft placement has developed as a safe and effective treatment for various diseases of the descending aorta and, recently, even in delicate anatomic regions such as the aortic arch. The aim of this study is to review our clinical experience with endovascular treatment of aortic arch aneurysms after surgical transposition of supra-aortic vessels. METHODS: Fifteen patients received thoracic stent-graft implants after aortic debranching for repair of aortic arch aneurysms during the 3-year period ending December 31, 2005. All patients were not candidates for standard endovascular repair due to inadequate proximal landing zones on the aortic arch. Device design and implant strategy were determined by an evaluation of aortic morphology with angiography and computed tomography (CT) scanning. Stent-grafts were used to repair the arch after supra-aortic vessel transposition was performed. The endografts were implanted transfemorally or via an iliac Dacron conduit graft using standardized endovascular techniques. Follow-up was 100% complete (mean, 18 +/- 2.5 months; range, 12 to 36 months). Outcome variables included death and treatment failure (endoleak, aortic rupture, reintervention, or aortic-related or sudden death). Follow-up included clinical examination, chest radiograph, and CT at discharge, 6 months after stent-graft placement, and yearly thereafter. RESULTS: Stent-graft deployment success was 100% after staged supra-aortic vessel transposition. Patency of all endografts and conventional bypasses was 100%. No endoleak or graft migration was observed. There were no neurologic complications. One patient died 2 months after the procedure from pulmonary complications. CONCLUSION: Repair of aortic arch aneurysms by sequential transposition of the supra-aortic branches and endovascular stent-graft placement is feasible. Extended application of this technique will enable safe and effective treatment of a highly selected subgroup of patients with aortic aneurysms by avoiding conventional arch aneurysm repair in deep hypothermia and circulatory arrest.     

Emergency aortic arch replacement using the debranch-first technique with a custom-made prosthesis

Acute aortic arch dissections represent life-threatening conditions with a high rate of mortality and neurological complications. Past longer techniques included an “en bloc” replacement of epiaortic vessels or the frozen elephant trunk (FET) procedure with conventional grafts for chronic dilatation. In this report, we described a case of an acute aortic dissection in a patient with aberrant right subclavian artery and challenging sovra-aortic vessel anatomy, treated with the new custom-made E-Vita Open Plus FET graft.     

Total aortic arch replacement through a median approach]

Seven patients underwent total aortic arch replacement only through a median approach since March 1990, in our institute. The woven Dacron graft with three side arm branches were used. After the proximal anastomosis at the ascending aorta, open distal anastomosis at the descending aorta was performed in five cases, under circulatory arrest of the lower body using separate perfusion to the brain. In two cases with true aneurysms involving the aortic arch, occlusion balloon catheters were employed for distal anastomosis. The anastomosis of the arch vessels was performed after coronary reperfusion. There was no early operative death, and our results demonstrate that total arch replacement can be safely accomplished through a median approach with an acceptably low operative risk.     

Simultaneous repair of arch and abdominal aortic aneurysms

Objective: Atherosclerotic aneurysms in the aortic arch are associated with abdominal aortic aneurysms in up to 37% of cases. We have developed a single-stage approach to the repair of both aneurysms using a temporary bypass. Subjects: Since November 1996, 5 patients underwent simultaneous repair of aneurysms in the aortic arch and in the infrarenal abdominal aorta, using a new temporary bypass graft technique. Entire arch replacement with simultaneous abdominal aortic aneurysmectomy was performed in one patient. The other 4 patients underwent distal hemiarch replacement distal from the orifice of the brachiocephalic artery with simultaneous repair of the abdominal aortic aneurysm. Method: For the entire arch replacement procedure, blood flow to all major branches of the aortic arch was established using a bifurcated graft. This graft anastomosed to the ascending aorta was used as the proximal inflow of the temporary bypass graft. For the hemiarch replacement procedure, the proximal inflow segment of the temporary bypass graft was anastomosed to the brachiocephalic artery. In both cases, the distal outflow segment of the temporary bypass graft was the graft used for repair of the abdominal aortic aneurysm. In order to prevent any clamp injury, Teflon felt was tightly wrapped around the aorta before the clamp was applied. Results: Evaluation of the hemodynamic parameters measured during cross-clamping of the aortic arch revealed stable distal perfusion to the visceral organs and no excessive increase in cardiac afterload. All patients had an uneventful postoperative course and were discharged within 1 month of surgery. Conclusion: Our temporary bypass method is recommended for simultaneous replacement of aneurysms in the aortic arch and the abdominal aorta.     

Successful shrinkage of distal arch and proximal descending aortic aneurysm after transaortic endovascular stent-grafting.

OBJECTIVES: Although endovascular stent-grafting is available for atherosclerotic thoracic aneurysms, it is unknown whether the excluded thrombosed aneurysms shrink. We evaluated serial changes in distal aortic arch or proximal descending aortic aneurysms excluded space after transaortic stent-grafting. METHODS: Thirty-four patients with true distal aortic arch or proximal descending thoracic aortic aneurysms were treated by stent-grafts introduced via proximal arch aortic incisions. Follow-up included computed tomographs (CT) every 6 months in 31 patients. The maximum dimensions for excluded space and aneurysmal diameters were measured and evaluated to determine whether the aneurysmal space had decreased or shrunken following this alternative procedure. RESULTS: Two hospital deaths (5.9%) were caused by a cerebral embolism and a peri-operative myocardial infarction. Another case died from pneumonia a year after surgery. Thirty-one cases (91%) survived during follow-up, but one case suffered from paraplegia (2.9%). The follow-up period ranged from 10 to 72 months (average 39.3+/-27.2 months). There were no aneurysmal ruptures during follow-up. Post-operative serial CTs showed a disappearance or a significant shrinkage of the excluded aneurysmal space in 30 of the 31 cases (97%); one case suffered endoluminal leakage. CONCLUSIONS: Transaortic endovascular stent-grafting is feasible for distal aortic arch or proximal descending aortic aneurysms. The excluded aneurysmal space disappears or shrinks after successful stent-graft placement.     

Hybrid procedures for the treatment of aortic arch aneurysms

Aortic arch aneurysms present a significant clinical challenge. Historically, open repair has been the mainstay of therapy, but it is associated with significant morbidity and mortality. In particular, the risk of stroke is not insignificant. The development of endovascular therapies has allowed for the less invasive treatment of thoracic aortic aneurysms using endograft therapy. This treatment is limited by the need for "healthy" aorta proximal and distal to the aneurysm in order to get an appropriate seal. This limits use of endografts in the aortic arch as treatment of aneurysms in this location would necessitate coverage of critical brachiocephalic vessels including the innominate and left carotid arteries. To overcome these limitations, hybrid approaches to arch aneurysm repair have been developed. These include partial arch reconstruction through a median sternotomy, or extra-anatomic arch vessel bypass depending on the location of the aneurysm and the patients overall medical condition. These are accompanied by the placement of a thoracic stent-graft at the same setting (either antegrade or retrograde) or at a subsequent procedure. Outcomes evaluating these procedures are just beginning to become available in significant numbers. The outcomes, however, demonstrate these are durable procedures that may provide a viable alternative to conventional aortic arch surgery. As experience with these procedures grows, our understanding of the factors affecting outcomes will be clearer, and the use of these procedures will become associated with even lower morbidities and mortality. The further evolution of aortic endograft technology, however, will ultimately allow for complete endovascular treatment of the entire aortic arch.     

Simultaneous repair of arch and abdominal aortic aneurysms. A simple new technique using a temporary bypass graft.

OBJECTIVE: Atherosclerotic aneurysms in the aortic arch are associated with abdominal aortic aneurysms in up to 37% of cases. We have developed a single-stage approach to the repair of both aneurysms using a temporary bypass. SUBJECTS: Since November 1996, 5 patients underwent simultaneous repair of aneurysms in the aortic arch and in the infrarenal abdominal aorta, using a new temporary bypass graft technique. Entire arch replacement with simultaneous abdominal aortic aneurysmectomy was performed in one patient. The other 4 patients underwent distal hemi-arch replacement distal from the orifice of the brachiocephalic artery with simultaneous repair of the abdominal aortic aneurysm. METHOD: For the entire arch replacement procedure, blood flow to all major branches of the aortic arch was established using a bifurcated graft. This graft anastomosed to the ascending aorta was used as the proximal inflow of the temporary bypass graft. For the hemi-arch replacement procedure, the proximal inflow segment of the temporary bypass graft was anastomosed to the brachiocephalic artery. In both cases, the distal outflow segment of the temporary bypass graft was the graft used for repair of the abdominal aortic aneurysm. In order to prevent any clamp injury, Teflon felt was tightly wrapped around the aorta before the clamp was applied. RESULTS: Evaluation of the hemodynamic parameters measured during cross-clamping of the aortic arch revealed stable distal perfusion to the visceral organs and no excessive increase in cardiac afterload. All patients had an uneventful postoperative course and were discharged within 1 month of surgery. CONCLUSION: Our temporary bypass method is recommended for simultaneous replacement of aneurysms in the aortic arch and the abdominal aorta.     

Combined Median Sternotomy and Posterior Lateral Thoracotomy: A Method for Proximal and Distal Thoracic Aortic Exposure

A method for exposure of the heart, ascending aorta, aortic arch vessels, and descending thoracic aorta in a single surgical field is presented. Five illustrative cases are reviewed. Indications for use include trauma to the aorta and arch vessels, aneurysms or dissections, ductus aneurysms, or complex or secondary coarctations of the aorta.     

Hybrid repair of aortic arch aneurysms: a totally extrathoracic approach with branched endografts in two patients

Of all of the aortic segments, the aortic arch is the last frontier for endovascular treatment. The main difficulty for arch repair is the lack of an appropriate proximal landing zone of at least 2 to 3 cm required for endograft sealing and anchoring to diminish the risk of endoleaks or migration. We used branched endografts to treat two cases of aortic aneurysms that required complete arch endografting, with successful aneurysm exclusion.     

Combined endovascular and vascular surgical therapy of a blister-like distal internal carotid aneurysm in a patient with a right-sided aortic arch

Blood blister-like aneurysms (BBAs) are rare but challenging to treat owing to their fragile, thin walls and poorly defined necks. A right-sided aortic arch is an uncommon congenital cardiac anomaly with an estimated incidence of only 0.1% and presents a challenge to intubation at vessels above the aortic arch. This represents an extremely rare case of a BBA at the left internal carotid artery with a right-sided aortic arch treated with combined endovascular and vascular surgical therapy. We report the case and provide a short review of the relevant literature.     

Complications after hybrid repair of aortic arch aneurysm

Hybrid repair can be an alternative to conventional open repair of aortic arch aneurysms especially in high risk cases. A 77 year male patient presented to us with complaints of breathlessness and chest pain. Investigations revealed aortic arch aneurysm with healthy ascending and descending aorta. Hybrid repair including supra aortic debranching and relocation of the arch vessels to the ascending aorta was performed. Complications like poststent-implant syndrome, cerebrovascular accident and localized dissection of ascending aorta at the site of stenting occurred.     

Hybrid repair of an aortic arch aneurysm with complex anatomy: right aortic arch and anomalous origin of supra-aortic vessels

We performed a one-stage hybrid surgical and endovascular procedure to manage a 6.5-cm right aortic arch aneurysm associated with anomalous origin of the supra-aortic vessels in a 70-year-old man. Complete surgical rerouting of the supra-aortic vessels was followed by the endovascular repair of the right aortic arch aneurysm with a Zenith TX2 stent graft (Cook, Bloomington, Ind) and Z-track plus introducer system. The procedure was successfully completed with exclusion of the aortic arch aneurysm, and the patient was discharged on postoperative day 7. Aortic arch aneurysms with complex anatomy may be successfully treated with a less invasive hybrid approach using new generation devices.     

Der Frozen-Elephant-Trunk

The frozen elephant trunk (FET) technique is a hybrid procedure combining conventional and endovascular aortic surgery to allow 1?stage treatment of the aortic arch and the proximal descending aorta. The indications for the FET operation include several aortic pathologies, such as aneurysms, acute and chronic dissections with involvement of the (distal) arch and the proximal descending aorta. The hybrid prosthesis consists of a vascular graft for transverse arch replacement with supra-aortic revascularization and a distally located stent for endovascular treatment of the descending aorta. After antegrade stent grafting of the distal aortic segment, partial or total aortic arch replacement is performed via the conventional open technique. The FET operation is nowdays routinely performed in specialized aortic centers worldwide. This article gives an overview with resoect to the clinical indications, technical aspects and postoperative results of the FET operation.     

Simple hypothermic retrograde cerebral perfusion for brain protection during aortic arch surgery]

We have recently found that retrograde cerebral perfusion can be performed by simply elevating central venous pressure to 15 mmHg in the Trendelenburg position when the aortic arch is open during aortic arch surgery. During deep hypothermic (15 degrees C) perfusion of the lower half of the body with the descending aorta occluded, and with single cannulation of the right atrium for drainage, oxygen-saturated venous blood perfuses the brain retrogradely, supplying it with oxygen. This method renders clamping of the aortic arch and the arch vessels unnecessary. Eleven cases of aortic arch aneurysm (9 males, 2 females; 5 true aneurysms, 5 dissecting aneurysms, one combined aneurysm; mean age, 63 years) were operated using this technique, whose clinical significance was then evaluated. Median sternotomy was performed in 4 cases, left thoracotomy in 7. Patch replacement was performed in 2 cases and graft replacement in 9 cases (the proximal arch in 2, the whole arch in 2, the distal arch in 5). In two cases coronary artery bypass surgery using the internal thoracic artery was performed simultaneously via lateral thoracotomy. Operation time was 517 +/- 139 min, pump time was 211 +/- 34 min, cardiac arrest time was 84 +/- 34 min and the lowest rectal temperature was 15.7 +/- 1.1 degrees C. In the venous return, PO2 was 188 +/- 136 mmHg, and SO2 97.5 +/- 2.9%, the respective values in the retrogradely perfused blood in the aortic arch being 46 +/- 12 mmHg and 68.8 +/- 18.8%.(ABSTRACT TRUNCATED AT 250 WORDS)     

Great vessel management for endovascular exclusion of aortic arch aneurysms and dissections.

OBJECTIVES: To evaluate a recent approach for the endovascular repair of thoracic aortic aneurysms and dissections involving the aortic arch in high risk patients (HRP). METHODS: Amongst 102 thoracic aortic aneurysms and dissections, we treated 25 patients for aortic arch endovascular exclusion after transposition of the great vessels, of which 14 (56%) had thoracic aortic arch aneurysms and 11 type A and B chronic aortic dissections. Total transpositions were done in 15 cases (60%) and hemi-arch transpositions in 10. We then used Talent, Excluder and Zenith endografts in 12, seven and six cases, respectively. RESULTS: Surgical transpositions were complicated by one minor stroke, which worsened to a major stroke (4%) after endovascular exclusion. After endovascular exclusions, two patients (8%) died from catheterization related complications. One patient had a delayed minor stroke (4%). The successful exclusion rate was 92%. During follow-up (15+/-5.8 months), one patient (4%) developed unilateral limb palsy, successfully treated by CSF drainage. The late exclusion rate remained 92%. No stent-related complications were seen. CONCLUSIONS: Transposition of supra-aortic vessels allows the endovascular exclusion of the aortic arch in HRP. Aortic endografting after surgical transposition proved to be feasible and offers good mid-term results. Specialized surgical centers with both endovascular and surgical expertise are required to treat these patients.