Endovascular stent-grafting via the aortic arch for distal arch aneurysm: An alternative of endovascular stent-grafting in a complicated case.

A 67-year-old man with severe discomfort was diagnosed with a rupture of the thoraco-abdominal aneurysm, a distal arch aneurysm and triple coronary artery disease. After emergency surgery for a thoracoabdominal aneurysm, a scheduled surgery for coronary artery bypass grafting and endoluminal stent-grafting for the distal arch aneurysm was performed simultaneously. A stent-graft was introduced into the descending aorta via a small incision on the arch aorta. Open endovascular stent-grafting via the arch aorta is an alternative for repairing a distal arch aneurysm with coronary artery bypass grafting.     

Endovascular stent-grafting via the aortic arch for distal aortic arch aneurysm: an alternative to endovascular stent-grafting.

OBJECTIVE: We have experienced transaortic stent-grafting for treating distal arch aneurysm or type B dissection. This paper is to mainly report the surgical aspect of these procedures. METHODS: Fifteen patients underwent this surgery, including 12 men and three women ranging from 47 to 83 years. Twelve had aneurysms and three aortic dissection. Concomitant surgery was necessary in seven patients (coronary artery bypass grafting in five, tricuspid annuloplasty in one, and replacement of ascending aorta and/or total arch replacement in three cases). A stent graft (Gianturco Z-stent and Intervascular prosthesis) was loaded in a 30-F sheath catheter. Under circulatory arrest, selective cerebral perfusion was established, and the sheath catheter was inserted through aortotomy into descending aorta and the stent graft was deployed at an appropriate level. The proximal end of graft was sutured to the aorta just distal to the left subclavian artery with inclusion method at the posterior wall. Concomitant surgery was done during cooling or rewarming period. TEE was utilized to visualize every endovascular manipulation to avoid unintended intimal injury or misplacement of graft and to assess the surgical results in the operative theater. RESULTS: Aneurysm was successfully excluded except in one patient who had a proximal endoleak and distal endoleak due to underestimation of aortic diameter. There was one operative mortality caused by cerebral infarction, possibly due to debris from femoral arterial cannulation. In the remaining patients, there was no enlargement of residual aneurysm. The excluded aneurysmal sac gradually regressed and disappeared within 2 years in five patients and the thrombosed false lumen completely shrunk within 1 year in two patients. One patient had paraplegia, possibly because the graft was intentionally advanced deeply to cover the thick and fragile atheromatous layer in order to avoid destruction of the atheroma by an expanded graft. CONCLUSIONS: Endovascular stent graft via the aortic arch is an acceptable treatment for distal arch aneurysms close to or involving left subclavian artery or type B dissections, especially for those cases requiring other cardiac procedures. It can lead to regression and disappearance of aneurysm or dissection in the mid-term follow-up.     

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.     

Open stent-grafting for a distal aortic arch aneurysm with a endotracheal tube

An open stent-grafting for a distal aortic arch aneurysm with a endotracheal tube is presented herein. The graft which has a Gianturco Z stent at its distal end was successfully inserted into the descending thoracic aorta through a endotracheal tube without fluoroscopy. This technique might easily deploy the stent-graft without damage of aortic wall compared with other deployment methods.     

Open stent-grafting for the distal arch aneurysm using a new delivery sheath

Surgical graft replacement of the distal aortic arch aneurysm has been known to have rather poor outcome. Open stent-grafting has been employed in many institutions, but several complications have been reported. Especially, embolism of the distal artery by debris of aneurysmal wall is a serious complication. Therefore we have developed and applied a new delivery sheath. The sheath is constructed with a ready-made delivery sheath and a part of a ready-made tracheostomy tube. That is called "balloon sheath". Five patients underwent distal arch stent-grafting using the device, all of whom had excellent result. The merits of the sheath are smooth delivery of stent-graft and less invasiveness for aortic wall. The new device is considered to be able to prevent aortic wall injury and peripheral embolic complication during insertion of stent-graft.     

Endovascular stent-grafting through the aortic arch: an alternative approach for distal arch aortic aneurysm

BACKGROUND: Endovascular stent-grafting is an innovative procedure; we have developed a novel approach to treat distal arch aortic aneurysm through a small incision in the aortic arch. METHODS: Eight patients with thoracic aortic aneurysms were treated with an endovascular stent-graft that was introduced into the thoracic aorta through a small incision in the aortic arch. Of these patients, 7 had distal arch aortic aneurysms, and 1 had chronic aortic dissection of Stanford type B. Four of these patients had received concomitant coronary artery bypass grafting, and 1 patient had undergone tricuspid valvular annuloplasty. The stent-graft was introduced into the distal arch aorta and descending aorta through a small incision in the aortic arch, under selective cerebral perfusion and hypothermic circulatory arrest. RESULTS: The selective cerebral perfusion time ranged from 52 to 86 minutes (mean, 68 minutes) and the operating time from 289 to 422 minutes (mean, 318 minutes). There was no endoluminal leakage into the aneurysm. Seven patients survived and were discharged, but 1 patient suffered a cerebral infarction and died during the follow-up period. CONCLUSIONS: Placing an endovascular stent-graft through the aortic arch is an acceptable alternative treatment for distal arch aortic aneurysms.     

Open stent-grafting for adult patent ductus arteriosus with a distal aortic arch aneurysm

Closure of adult patent ductus arteriosus (PDA) is difficult for its variation. We report a case of open stent-grafting for a 67-year-old woman who had PDA and a concomitant distal aortic arch aneurysm. The pulmonary/systemic flow ratio was 1.88, and the pulmonary arterial pressure was 34/21(25). The operation was done through a median sternotomy under hypothermic cardioplegic arrest. We opened the anterior wall of the arch just distal to the left subclavian artery and placed a stent-graft into the descending aorta. At 5 months after discharge, three-dimensional computed tomography showsed disappearance of PDA and no endoleak of the stent-graft.     

Transposition of arch vessels and endovascular stenting of saccular aneurysm of distal arch--a case report

Endovascular repair of thoracic aneurysms has emerged as an attractive alternative especially in high-risk patients. However, the aortic curvature and potential coverage of the epiaortic vessels limit the use of stent-grafts in aneurysms located in the aortic arch. We report a case with a saccular aneurysm in the distal arch and proximal descending aorta, where we have transposed the epiaortic vessels to gain a longer proximal neck in the aortic arch to safely deploy an endovascular stent.     

Open stent-grafting applied with the Matsui-Kitamura stent to a distal arch aneurysm

An open stent-grafting applied with the Matsui-Kitamura (MK) stent to a distal arch aneurysm is presented herein. The graft using the MK stent at its distal end was successfully inserted into the descending thoracic aorta through a J-shaped sheath-introducer. The major advantages of this stent-graft include its flexibility, shape memory, and small profile when compressed, compared with other devices. This technique may be feasible and clinically effective in the treatment of distal arch aneurysm.     

Open stent-grafting for saccular aneurysms of the distal arch and descending aorta; report of a case

We report the utility of an open stent-grafting for saccular aneurysms of the distal arch and descending aorta. A 68-year-old man showed a radiological abnormality on a chest X-ray film. Chest computed tomography (CT) demonstrated saccular aneurysms of the distal arch and descending aorta. Open stent-grafting was performed using a homemade device. The postoperative course was uneventful. Postoperative CT showed satisfactory placement of the endograft, without extravasation. Open stent-grafting was a useful therapeutic procedure in this case of multiple aneurysms.     

Aortocaval fistula after endovascular stent-grafting of abdominal aortic aneurysm

The authors present a case report of a 79-year-old man with insufficient cardiac contractile function who underwent endovascular stent-grafting for an abdominal aortic aneurysm. Thirty months later, the aneurysm ruptured into the inferior vena cava and subsequently formed an aortocaval fistula caused by migration of the stent-graft. Urgent secondary endovascular stent-grafting successfully excluded the blood flow into the vena cava. Endovascular stent-grafting is deemed suitable for treating this serious disorder, especially in severely debilitated or compromised patients who might not withstand a standard surgical intervention. Furthermore, in patients with previous stent-grafting, since the primary stent-graft makes repair by open surgery more difficult, a secondary endovascular intervention is recommended if feasible.     

Total aortic arch replacement for distal aortic arch aneurysm with adhered left lung: report of a case

A 76-year-old man with a history of pleuritis and a cerebral infarct underwent a total arch replacement for an aneurysm of the distal aortic arch. Computed tomography revealed a true aneurysm having a maximum diameter of 70 mm as well as pleural thickening and calcification. Total arch replacement with selective cerebral perfusion was performed through median sternotomy and left thoracotomy. The myocardial ischemic time was shortened by reperfusion from the right axillary artery after the anastomosis of the proximal ascending aorta and the brachiocephalic artery. After the other branches of the arch were anastomosed, a distal anastomosis through the left thoracotomy was then performed using the pull-through method, enabling minimal decortication of the adhered lung. Our surgical procedure for distal arch aneurysm with adhered lung involves the addition of a left thoracotomy, but the reduction in the myocardial ischemic time and lung injury are of benefit.     

Chronic pseudoaneurysm of the aortic arch: a case report

Pseudoaneurysm of the thoracic aorta is a rare condition and usually occurs following blunt trauma. It is almost fatal in the absence of prompt surgical treatment. We describe the case of a 56-year-old male suffering from intermittent non-massive hemoptysis, mild dysphagia, and atypical chest pain for 1 month who has no history of trauma. A saccular aneurysm at the aortic arch between left common carotid artery and left subclavian artery was diagnosed by magnetic resonance imaging. Intraoperatively, compression of surrounding structures including trachea and esophagus by the aneurysmal sac (6 x 8 cm in diameter) was seen. Pseudoaneurysm adherent to the upper lobe of the left lung was resected and entire aortic arch replacement with a prosthetic graft was performed. Postoperative course was uneventful and neither specific changes on histologic examination nor any evidence of infection could be detected.     

Surgical treatment of an aortic arch aneurysm without cardio-pulmonary bypass: endovascular stent-grafting after extra-anatomic bypass of supra-aortic vessels.

A 70-year-old patient presented a large saccular aneurysm involving the whole aortic arch. Because of a past history of left thoracotomy and a high co-morbidity profile, we opted for a combined strategy, consisting of an extra-anatomic bypass of the supra-aortic vessels, followed by the endovascular implantation of a covered thoracic stent-graft. Endovascular stent grafting of aortic arch aneurysm, after extra anatomic bypass of supra-aortic vessels, appears as an attractive alternative strategy for high surgical risk patients.     

Hybrid treatment of a ruptured aneurysm in the distal aortic arch: report of a case

An 80-year-old man was transferred to our hospital for surgical treatment of a ruptured aortic arch aneurysm. Based on a history of severe heart failure and coronary artery bypass, we considered him unsuitable for conventional open repair. He underwent a hybrid repair, in the form of supra-aortic vessel debranching followed by endoluminal aortic repair. Although the ostia of the left carotid and left subclavian arteries were occluded by the stent-graft, the left supra-aortic vessels and the left internal thoracic artery attached to the coronary artery were perfused through an extra-anatomic bypass from the right axillary artery to the left carotid artery and the left axillary artery. After additional endovascular repair for recurrent hemosputum, the patient recovered without complications. Although continued follow-up is necessary, acute hybrid arch repair seems feasible for treating ruptured aortic arch aneurysms, even in the setting of severe heart failure and a previous coronary artery bypass.     

Immediate endovascular stent-grafting for leg ischemia secondary to acute aortic dissection: report of a case

Generally, extra-anatomical bypass grafting has been chosen for patients with leg ischemia secondary to acute aortic dissection. However, these patients are high-risk candidates for visceral vessel compromise as well. We present a case of leg ischemia secondary to acute aortic dissection, which was able to be treated by immediate stent-grafting. A 58-year-old male was transferred to our hospital for acute right-leg ischemia. Computed tomography revealed partial infarction of right kidney and severely compressed true lumen of abdominal aorta. Emergency endovascular stent-grafting was chosen to consider possible visceral vessel compromises instead of contemporary bypass grafting for leg ischemia. Pulsation of the right femoral artery was immediately achieved following stent-grafting. Primary entry closure using a Stent graft could be a treatment of choice for complications due to acute aortic dissection.     

A case of stent-graft implantation for distal arch aneurysm

A 74-year-old woman was pointed out distal arch aneurysm 4 years ago in another hospital. As the diameter has gradually increased, the operation was considered. At first a pig tail catheter was inserted from the right femoral artery to aortic arch in the cardiac catheterization laboratory. In the operating room, stent-graft was inserted using pig tail catheter. Post operative CT showed clot formation outside the stent-graft. This procedure was thought to be less invasive and safe.     

A case of successful reoperation for distal aortic arch pseudoaneurysm after replacement of descending aorta

The patient was a 69-year-old man who had undergone replacement of descending aorta under close clump technique. Hoarseness occurred 8 years after the operation. Computed tomography and aortography revealed a saccular aneurysm of the distal aortic arch. During surgery, the pseudoaneurysm originated from a intimal defect close to the proximal anastomotic site of the graft. Total aortic arch replacement was successfully performed under retrograde and selective cerebral perfusion. The postoperative course has been uneventful.     

Thoracic endovascular stent graft for late pseudoaneurysm formation after patch aortoplasty; report of a case

We report a case of a 51-year-old man presenting with pseudoaneurysm associated with a knitted Dacron patch used to repair coarctation of the aorta. At the age of 15 years, he underwent patch angioplasty for coarctation of the aorta. However the computed tomography( CT) scan, taken after 36 years, demonstrated pseudoaneurysm of the thoracic aorta at the anastmotic site. He was treated by endovascular stent graft using Gore-TAG 3115. His postoperative course was uneventful. Follow-up CT scan demonstrated no recurrence of pseudoaneurysm.