Endovascular repair after stent elephant trunk procedure for extensive thoracic aortic aneurysm

Hybrid surgical-endovascular procedure was conducted in a 46-year-old male with extensive thoracic aortic aneurysm. Ascending aorta and arch replacement combined with stent elephant trunk implantation was performed first. An open stent-graft was implanted into the descending aorta. One month later, endovascular repair was conducted. Postoperative CTA showed total coverage of the descending aorta by stent-grafts and the descending aortic aneurysm was totally thrombo-excluded. Stent elephant trunk may be a better alternative to conventional elephant trunk in hybrid surgical-endovascular approaches in treatment of extensive thoracic aortic aneurysm.     

经颈动脉腔内技术重建主动脉弓治疗Stanford A型夹层动脉瘤(附1例报告)

目的探讨血管腔内技术重建主动脉弓治疗升主动脉、主动脉弓病变的可行性。方法2005年,对1例StanfordA型夹层动脉瘤,腔内修复主动脉病变之前做右颈总动脉-左颈总动脉-左锁骨下动脉的旁路术;经右颈总动脉将修改的分叉支架型血管主体放入升主动脉,长臂位于无名动脉。短臂应用延长支架型血管延伸至降主动脉。通过腔内技术重建主动脉弓实现累及升主动脉和主动脉弓主动脉病变的微创治疗。结果腔内修复术后移植物形态良好,血流通畅,病变被隔绝,脑、躯干、四肢循环稳定。无严重并发症。结论该手术方案设计合理、技术可行。可能成为复杂胸主动脉病变新的腔内治疗模式。     

Two-staged hybrid surgery for an extended thoracic aortic aneurysm with Komerell's diverticulum

We have successfully performed 2 staged hybrid operation for an extended thoracic aortic aneurysm with Komerell diverticulum, which lessened surgical stress of the patient with avoidance of postoperative complications. An 82-year-old man who had been under observation for thoracic aortic aneurysm was admitted to the hospital with continuous chest discomfort. The patient initially underwent graft replacement for an ascending and arch aneurysm by using the elephant trunk technique. Thirty-five days later, he underwent endovascular repair for the residual descending thoracic aneurysm. The postoperative course was uneventful, and postoperative computed tomography (CT) revealed no stent migration and just a little type II endoleak. This 2 staged hybrid approach might be less invasive than the conventional approach, and be a potential therapeutic option for high risk patients with an extended thoracic aortic aneurysm.     

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.     

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.     

Modular branched stent graft for endovascular repair of aortic arch aneurysm and dissection

PURPOSE: We describe a modular stent graft for use in endovascular repair of aneurysms of the aortic arch. METHOD: Carotid-carotid and left carotid-subclavian bypass grafts are created surgically. Two large, fully stented grafts are inserted endoluminally. The proximal component is bifurcated, with a wide proximal trunk and two distal limbs, one long and narrow, the other short and wide. This component is inserted through the carotid artery and deployed with the trunk and short wide limb in the ascending thoracic aorta; the long narrow limb opens into the innominate artery. After delivery system removal and carotid artery repair, a distal component is inserted through a femoral approach to bridge the gap between the short, wide distal limb of the proximal component and the nondilated descending thoracic aorta. The result is a branched stent graft, implanted proximally into the ascending aorta and distally into the innominate artery and descending thoracic aorta. CONCLUSION: The system has been used successfully to treat a large wide-necked pseudoaneurysm of the aortic arch.     

Anesthetic management for distal aortic arch aneurysm stent grafting

A 76-year-old woman with thoracic aortic aneurysm involving distal aortic arch was scheduled for graft replacement from ascending to proximal aortic arch with endovascular stent graft to descending aorta. Surgical procedures were performed under median sternotomy with hypothermic systemic circulation arrest and selective cerebral perfusion. The stent graft composed of 30 mm Gianturco Z stent and 27.5 mm woven Dacron graft was introduced into the descending aorta under the guidance of transesophageal echocardiography (TEE) and fluoroscopy. Ascending and proximal aortic arch replacement was then performed with four branched woven Dacron graft. The aortic pathology was confirmed by TEE and the extent of the aneurysmal lesion was defined. TEE was also useful to find the dislodgement of the stent graft after deployment. This surgical technique, being less invasive than conventional thoracotomy, would be indicated for elderly patients with distal aortic arch aneurysm. TEE is the vital imaging technique for placement of the stent graft, as well as for intraoperative cardiac monitoring.     

升主动脉替换联合三分支支架血管术中置入治疗急性A型主动脉夹层

目的 总结升主动脉人工血管替换联合三分支支架血管术中置入治疗急性Stanford A型主动脉夹层的初步经验.方法 2008年6月至2009年9月20例急性A型主动脉夹层病人接受了升主动脉人工血管替换和三分支支架血管置入术.体外循环鼻咽温度降至20℃时,停止下半身灌注,经无名动脉近端升主动脉横断切口,将三分支支架血管置入主动脉弓和近端胸降主动脉真腔内,并将其分支支架血管依次置入左锁骨下动脉、左颈总动脉和无名动脉.将主干支架血管的近端与无名动脉近端的升主动脉切口重建后与替换近端升主动脉的人工血管端端吻合.结果 所有病人术中均顺利地置入三分支支架血管,平均体外循环(163.2±19.2)min,主动脉阻断(89.4±10.0)min,低流量选择性脑灌注和下半身缺血(32.7±6.6)min.术后出现短暂性神智障碍1例,急性肾功能衰竭1例.20例均治愈出院.术后3个月电子束CT检查结果示,主干支架血管及分支支架血管通畅、无扭曲;支架血管置入部位夹层假腔闭合;16例远端胸降主动脉夹层假腔闭合.结论 三分支支架血管术中置入是简化急性主动脉夹层者主动脉弓重建、提高手术安全性的一种有效方法.主要适应证为弓内内膜无破口而需主动脉弓重建的急性A型主动脉夹层病人.支架血管大小、分支支架血管间的距离选择和放置过程中避免内膜损伤是术中三分支支架血管成功放置的关键.

Abstract：

Objective To report the primary experience of open placement of triple-branched stent graft for acute Stanford type A aortic dissection. Methods Between June 2008 and September 2009, 20 well-selected patients with acute Stanford type A aortic dissection underwent open placement of triple-branched stent graft for total arch reconstruction. When core cooling to a 20℃ nasophageal temperature, perfusion to the lower body was discontinued and the ascending aorta was transected at the base of the innominate artery. Through a transverse incision, the triple-branched stent graft was inserted into the true lumen of the arch and descending aorta, and each side arm of the stent graft was positioned one by one into the arch branches.The transected stump of the ascending aorta was reconstructed by inner proximal stent-free dacron tube of the main graft and outer teflon felt, and subsequently continuous anastomosis to the 1-branched dacron tube graft was made. Results Open placement of triple-branched stent graft was technically successful in all patients. The mean cardiopulmonary bypass time, aortic cross-clamp time and lower body arrest time were (163.2 ±19.2) min, (89.4 ±10.0) min and (32. 7 ±6. 6)min, respectively. Transient postoperative neurological dysfunction was observed in 1 patient and acute renal failure in 1 patient. All patients were discharged from the hospital. Their computed tomographic scans at 3 months postoperatively showed that all stent grafts were fully opened without distortion. In the vascular stent implantation site the dissected false lumen was eliminated. The false lumen of the descending aorta distal to the stent graft was closed with thrombus in 16 cases. Conclusion Open placement of triple-branched stent graft is a new effective technique for total arch reconstruction in acute type A aortic dissection. Patients have the indications of the extensive primary repair of the thoracic aorta without primary intimal tears in the arch may be the best candidates for this new technique. The size of the stent graft, the distances between two neighboring side arm grafts and the prevention of the intimal trauma during the placement are crucial for successful open placement of triple-branched stent graft.     

Endovascular repair of thoracic aortic aneurysm associated with right-sided aortic arch: report of two cases

Right-sided aortic arch (RAA) is a rare congenital disorder. We describe herein two cases of thoracic aortic aneurysm with a right aortic arch and right-sided descending aorta treated with thoracic endovascular aortic repair (TEVAR). In one case, a 70-year-old man with Edwards type 1 RAA underwent TEVAR using a Relay stent-graft (Bolton Medical, Barcelona, Spain). In another case, a 72-year-old woman with Edwards type 3 RAA underwent TEVAR using a Kawasumi Najuta stent-graft (Kawasumi Laboratories, Inc., Tokyo, Japan) with the “buffalo horn chimney technique”, our original method for left subclavian artery flow preservation. The postoperative courses were uneventful. Postoperative computed tomography showed complete exclusion of the aneurysm without endoleakage. Compared to conventional open surgical repair, TEVAR is challenging in patients with a RAA and right-sided descending aorta. However, our results showed that TEVAR might be feasible and a treatment option even in a patient with a RAA and right-sided descending aorta.     

Complex thoracic aortic aneurysm: a combined open and endovascular approach

The authors wish to describe a combined open and endovascular approach to repair a complex thoracic aortic aneurysm. A 72-year-old man with chronic obstructive pulmonary disease, aortic valvular insufficiency and diffuse thoracic aortic aneurysm underwent aortic valve and ascending aorta replacement by a Bentall-procedure and replacement of arch aneurysm using the elephant trunk technique, performed in a first procedure. During the second procedure, endovascular stenting of the descending thoracic aorta was done. Only a few similar case reports have been presented. Endovascular repair after an elephant trunk procedure for complex thoracic aortic aneurysms is an elegant approach to deal with such mega aortas. Further research is necessary to compare open and endovascular repair and to determine long-term follow-up with regard to endoleaks and mortality.     

Use of the abdominal aorta as an alternative access site for thoracic aortic stent graft placement

The treatment of thoracic aortic pathology has undergone a paradigm shift in recent years, with a trend toward less invasive endovascular techniques and away from open surgical repair. Reports on the successful use of endografts in the thoracic aorta have demonstrated decreased morbidity and mortality of these procedures compared with traditional open repair. However, some patients are not candidates for an endovascular approach because of a short proximal landing zone, arch angulation, luminal irregularities, or a large diameter of the transverse arch and the proximal descending aorta. Other patients are excluded because of distal pathology or anatomic irregularities. This article presents 2 patients with thoracic aortic pathology, and both had inadequate proximal landing zones and small, calcified iliac arteries prohibiting femoral or iliac access. Successful repair of these patients was achieved by a staged procedure using a brachiocephalic debranching technique, followed by direct infrarenal aortic cannulation through a limited celiotomy.     

Delayed retrograde aortic dissection after endovascular stenting of the descending thoracic aorta

A 66-year-old patient underwent emergency endovascular repair of a descending thoracic aneurysm because of suspected aortic rupture. Two weeks later, a small saccular aneurysm of the aortic arch was treated with open surgery. An unexpected intraoperative finding was retrograde dissection of the aortic arch and of the ascending aorta that was not seen on the postprocedural computed tomographic scans after endografting. The ascending aorta, the aortic arch, and the proximal part of the descending thoracic aorta were successfully replaced with a Dacron graft with deep hypothermia, circulatory arrest, and retrograde cerebral perfusion. Awareness that this life-threatening complication that necessitates extensive cardiovascular surgery can occur not only during or immediately after endovascular stenting of the thoracic aorta but also as much as several days or perhaps even weeks after the procedure is important.     

One-stage total thoracic aortic repair for mega-aorta using frozen elephant trunk technique

We report the case of a 71-year-old female with mega-aorta extending from the ascending aorta to the descending aorta, who was successfully treated with a one-stage total thoracic aortic repair by the frozen elephant trunk technique using a stent-graft. We used a home-made frozen elephant trunk with four giant-turco Z-stents on the distal side that was inserted into the downstream descending aorta via an aortic arch guiding pull-through wire. The stent-graft was distally positioned at the level of the 12th thoracic vertebra after total arch replacement had been performed using a four-branch graft. The postoperative course was good, and there was no paraplegia or other complications. A postoperative computed tomography scan demonstrated complete thrombosis of the descending thoracic aneurysm without endoleak. In conclusion, the frozen elephant trunk was effective as a one-stage operation for mega-aorta.     

Ruptured aortic arch aneurysm: transposition of aortic arch branches after insertion of thoracic endovascular stent with extra-anatomic brain perfusion

Conventional surgical treatment of a ruptured aortic arch aneurysm is a challenging approach with a high rate of adverse outcomes. The midsternotomy can be complicated by total aortic disruption with often fatal massive hemorrhage. A preliminary cardiopulmonary bypass with peripheral cannulation and cooling is often preferred. Endovascular stents have been used in patients with thoraco-abdominal aneurysms, with good results. Its lone utilization for rupture of aortic arch aneurysm is not feasible because of the unavoidable occlusion of cerebral vessels' origins. A previous aorto-bicarotid bypass is mandatory and it requires the midsternotomy. Hence, we developed a combined technique. We performed a hybrid approach in a 74-year-old patient, affected by an aortic arch aneurysm, ruptured in its antero-inferior portion. First we ensured brain perfusion with a temporary surgical extra-anatomic (femoral-bicarotid) bypass. Then an endovascular stent graft was expanded from the distal portion of ascending aorta to the proximal one of the thoracic aorta, thus excluding the ruptured portion of the aortic arch. Then the patient underwent the definitive aorto-carotid bypass. This specific combined technique allows the complete treatment of a ruptured arch aneurysm, lowering the risks connected with sternothomic approach, mainly with previous cardiopulmonary bypass and deep hypothermic circulatory arrest.     

Endovascular stent grafting of the descending thoracic aorta after arch repair in acute type A dissection

An endovascular stent graft was successfully deployed to the primary entry site in the proximal descending thoracic aorta after total aortic arch replacement using the "elephant trunk" technique in acute type A aortic dissection. The residual false lumen of the descending aorta was thrombosed completely after stent grafting. The elephant trunk was feasible for a proximal landing zone for stent grafting of the descending aorta. Stent grafting in combination with aortic arch replacement was a safe and effective procedure, and may be an alternative choice in carefully selected patients with type A aortic dissection.     

Challenges of endovascular tube graft repair of thoracic aortic aneurysm: midterm follow-up and lessons learned

OBJECTIVES: Endovascular stent-graft repair has great potential in treatment of thoracic aortic aneurysms. This study analyzed a single center's experience with first-generation commercially produced thoracic stent grafts used to treat descending thoracic aortic aneurysms. METHODS: Over 58 months 84 patients underwent endovascular stent-graft repair of descending thoracic aortic aneurysms; 22 patients received the Gore TAG stent graft, and 62 patients received the Talent thoracic endovascular stent-graft system. Each patient was enrolled in one of three distinct US Food and Drug Administration trials at Mount Sinai Medical Center in accordance with strict inclusion and exclusion criteria, including suitability for open surgery, aneurysm anatomy, and presence of comorbid medical illness. Mean age of this cohort was 71 +/- 12 years. There were 54 men and 30 women, and 74 (88%) had three or more comorbid illnesses. Primary technical success was achieved in 76 patients (90%). Mean follow-up was 15 months (range, 0-52 months). RESULTS: Successful aneurysm exclusion was achieved in 69 patients (82%). Major procedure-related or device-related complications occurred in 32 patients (38%). There were six proximal attachment failures (8%), four distal attachment failures (6%), one intergraft failure (1%), two mechanical device failures (3%), five periprocedural deaths (6%), and five late aneurysm ruptures (6%). At 40 months, overall survival was 67% (+/-10%), and freedom from rupture or from type I or type III endoleak was 74% (+/-10%). CONCLUSION: While promising, this midterm experience with commercially available devices highlights the shortcomings of current stent-graft technology. Three significant advancements are required to fulfill the potential of this important treatment method: a stent graft with a durable proximal and distal fixation device, enhanced engineering to accommodate high thoracic aortic fatigue forces, and a mechanism to adapt to aortic arch and visceral segment branches to enable treatment of lesions that extend to or include these vessels.     

Extensive primary repair of the thoracic aorta in Stanford type A acute aortic dissection by means of a synthetic vascular graft with a self-expandable stent

OBJECTIVES: To minimize any residual false lumen when operating on patients with an acute type A aortic dissection, we tried to perform extensive primary repair of the thoracic aorta with the modified elephant trunk technique. The early and midterm results of these surgical interventions are reported and evaluated. METHODS: Among the acute type A aortic dissections with extensive false lumen encountered since December 1997, 19 consecutive patients, 15 DeBakey type I with the tear in the ascending, transverse, or both aortas, and 4 DeBakey type III-D with the tear located in the descending aorta, underwent insertion of a synthetic graft with a distally anchored stent in the descending thoracic aorta. The interpolation method was used as an introducer combined with total replacement of the aortic arch by using a synthetic branching graft with only a median sternotomy. RESULTS: One patient died, and 18 were discharged after full recovery. Postoperative computed tomographic scans showed that no residual false lumina were present proximal to the diaphragmatic level, and no false lumina were found in 10 patients. Two patients with acute ischemia of the right kidney caused by narrowing of the true lumen, as demonstrated by radiographic computed tomography, improved significantly after surgical intervention with restoration of blood flow in the true lumen. Paraplegia was not observed in any patient. CONCLUSIONS: In emergency operations for an acute type A aortic dissection, the operation is often limited to replacing the ascending aorta because priority is given to saving the patient's life. However, it is possible to perform extensive primary repair of the thoracic aorta with relative safety by interpolating a synthetic graft with a self-expandable stent.     

Stent-graft repair of traumatic thoracic aortic disruptions

OBJECTIVE: Blunt traumatic thoracic aortic disruption results in pre-hospital death in 80% to 90% of patients. Because of the significant surgical morbidity and mortality associated with open operative repair, endovascular stent-graft repair has been investigated. The objective of this study was to evaluate the efficacy of thoracic aortic disruptions treated with commercially available proximal aortic extension cuffs. METHODS: Nine patients with multiple system trauma (age range, 16-42 years) were seen after motor vehicle accidents between January 1, 2003, and April 1, 2004. Chest x-ray findings warranted thoracic computed tomography scans, which revealed disruptions of the thoracic aorta. Aortograms delineated the extent of the aortic injuries and identified a "landing zone" (neck length range, 1.5-2.0 cm) distal to the subclavian artery but proximal to the tear. The repairs were performed with AneuRx (n= 8) and Excluder (n = 1) proximal aortic extension cuffs. A left femoral artery approach was used in 6 patients, a suprainguinal retroperitoneal approach with an iliac conduit in 2 patients, and direct tunnel in 1 patient. An Amplatz super-stiff wire was placed in the right axillary artery to enable easy tracking of the endografts, and left brachial artery access was used for arch arteriography. RESULTS: In each patient the stent-graft cuff was deployed adjacent to the left subclavian artery, with successful exclusion of traumatic disruptions verified at intraoperative arteriography and on computed tomographic scans obtained within 48 hours of initial repair. One patient required a second cuff for exclusion of a type I endoleak at the distal attachment site 1 month after the initial endograft repair. There were no procedure-related deaths; 1 patient, however, died of other injuries. CONCLUSIONS: Stent-graft repair of traumatic thoracic aortic disruptions is technically feasible. Placement of a stiff wire in the right axillary artery and percutaneous left brachial artery access for arteriography are useful adjuncts during endograft deployment. Endovascular stent grafts may enable definitive repair or serve as a bridge until the patient is stable enough to undergo an operation, if necessary. This technique warrants further investigation.     

Extending hybrid approach to residual Stanford type A dissecting aortic aneurysm

Residual Stanford type A dissecting aortic aneurysm was frequently encountered several years after emergent repair. Surgical approach remained challenging and hazardous, not only due to the extensive involvement of the dilated false lumen but also the high comorbidity of redo sternotomy and extensive thoraco-abdominal procedure. We present a modified hybrid technique incorporating arch replacement with bifurcated graft to relocate supra-aortic branches followed by anastomosis with reverse sleeve graft of elephant trunk over distal arch. After stent graft insertion over proper landing zone, all the communicating holes could be sealed and the compressed true lumen of descending aorta would be fully dilated. This technique not only simplified some laborious situations but also simultaneously resolved the entire thoracic dissection segment with an acceptable and optimal midterm result.     

Endovascular stent-graft repair of penetrating descending thoracic aortic ulcer

This article presents a case in which covered stent-graft cuffs were used to treat a penetrating ulcer of the descending thoracic aorta. An 80-year-old woman presented with penetrating ulcer in the descending thoracic aorta. Two endovascular stent graft cuffs were used for total exclusion of the penetrating ulcer, because the patient had a high operative risk. Her postoperative course was uneventful, and follow-up computed tomographic angiography showed complete coverage of the ulcer without evidence of leak. This case demonstrates that endoluminal stent-graft repair of penetrating descending thoracic aortic ulcers is a safe, less-invasive treatment, especially for elderly, high-risk patients.