Ann Thorac Surg 2000;70:1251-1254
© 2000 The Society of Thoracic Surgeons
Original articles: cardiovascular
Endovascular stent-grafting through the aortic arch: an alternative approach for distal arch aortic aneurysm
Taijiro Sueda, MDa,
Masanobu Watari, MDa,
Kenji Okada, MDa,
Kazumasa Orihashi, MDa,
Yuichiro Matsuura, MDa
a First Department of Surgery, Hiroshima University School of Medicine, Hiroshima, Japan
Address reprint requests to Dr Sueda, First Department of Surgery, Hiroshima University School of Medicine, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
e-mail: sueda{at}mcai.med.hiroshima-u.ac.jp
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Abstract
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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.
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Introduction
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The endoluminal repair of aneurysms is an innovative technique for the treatment of aortic aneurysms. It was originally applied to the descending thoracic aorta and to infrarenal abdominal aortic aneurysms by the transcatheter placement of an endoluminal graft; this procedure has replaced open operations in several institutions [1, 2]. In most patients, the stent-graft is inserted percutaneously by a transfemoral approach [3]. However, in patients with thoracic aneurysm or aortic dissection, there is often kinking of the iliac arteries, of the abdominal aortic aneurysm, or both, and the percutaneous insertion of the stent-graft is difficult in such patients. In addition, some patients with thoracic aortic aneurysms have other cardiac disorders, and concomitant cardiac repair is mandatory. We have therefore developed a technique that involves the surgical insertion of an endoluminal stent-graft for distal arch aortic aneurysms and chronic aortic dissections of Stanford type B through a small incision in the aortic arch instead of by a transfemoral approach, especially for patients who also require cardiac procedures such as coronary artery bypass grafting.
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Patients and methods
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Eight patients were enrolled in this study. There were 6 men and 2 women, and their mean age was 69.1 ± 6.7 years (range, 64 to 79 years). Seven patients had distal arch aortic aneurysms, which were located at the root of the left subclavian artery and extended to the descending thoracic aorta. The other patient had a chronic aortic dissection of Stanford type B (Table 1). Four patients had severe coronary artery disease, and 1 had tricuspid valve regurgitation. Two patients had stenosis of iliac arteries, femoral arteries, or both, caused by arteriosclerosis obliterance. Previous surgery for a rupture of the thoracoabdominal aortic aneurysm had been performed in patient 2, who had undergone this endoluminal stent-grafting and triple coronary bypass grafting. Patients 4 and 5 both had left subclavian artery aneurysms and thus required left subclavian arterial reconstruction.
The operation was performed through a median sternotomy. Extracorporeal circulation was established by aortic cannulation through the ascending aorta and venous drainage through the right atrium, except in patient 3, who had calcification of the ascending aorta and thus received femoral arterial perfusion through the left femoral artery instead. While the body temperature was cooled to 25°C, the coronary artery bypass grafting or the tricuspid valve annuloplasty was performed under blood cardioplegic arrest. Selective cerebral perfusion was performed through both cervical arteries with small arterial cannulas at an average blood flow rate of 500 mL/min (10 mL · kg-1 · min-1) when the rectal temperature decreased to 25°C. Then, hypothermic circulatory arrest for the peripheral body was instituted at a rectal temperature of 25°C. The hemicircular aortotomy was performed on the anterior wall of the arch of the aorta and was extended to the root of the left subclavian artery. A Gianturco Z-stent (diameter of 30 mm or 40 mm; Cook, Inc, Bloomington, IN) was inserted into the distal end of the Dacron graft (porosity 250 mL/m2, with a diameter from 22 mm to 30 mm; Intervascular, Inc, Clearwater, FL) and sutured to the exterior of the graft. This stent-graft was introduced into a sheath catheter with a 30F diameter. The sheath catheter was then inserted into the descending thoracic aorta, and the stent-graft was delivered into the descending thoracic aorta beyond the distal end of the aneurysm or the entry of the aortic dissection (Fig 1A). After the stent-graft was positioned, the distal end of the stent-graft was dilated with a balloon cannula and attached to the wall of the descending aorta. The proximal end of the stent-graft was trimmed in size, and the posterior wall of the proximal end of the stent-graft was sutured onto the posterior wall of the aortic arch just distal to the left subclavian artery. The incision orifice of the arch aorta was closed with the anterior wall of the endovascular graft by interrupted buttress sutures with a Dacron felt strip (Fig 1B). The body temperature was then rewarmed. During the rewarming, selective cerebral perfusion was terminated, and the proximal ends of venous grafts for coronary reconstruction were sutured to the ascending aorta under partial aortic cross-clamping. The extracorporeal circulation was terminated when the patient attained a rectal temperature of 36°C. The selective cerebral perfusion time, the time from the termination of the extracorporeal circulation to complete closure of the chest wall, and the operative time were then compared with corresponding times for 12 patients in whom a total arch replacement was performed in conventional fashion using the branched graft during the same period.
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Fig 1. Operative procedure for endoluminal stent-grafting through a small incision in the aortic arch. (A) The stent-graft was introduced into the sheath catheter. The sheath catheter was then inserted into the descending thoracic aorta, and the stent-graft was delivered into the descending thoracic aorta beyond the distal end of the aneurysm. (B) After the stent-graft had been positioned, the graft was dilated and trimmed in size. The proximal end of the stent-graft was sutured onto the wall of the aortic arch just distal to the left subclavian artery.
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The results were recorded as means ± standard deviation, and statistical significance was calculated using Student’s t test for unpaired observations. A p value of less than 0.05 was considered to be statistically significant.
This procedure was indicated for patients with distal arch aortic aneurysm or with proximal descending aortic aneurysm, in whom both the ascending aorta and the proximal arch aorta had not been diagnosed with aneurysms by preoperative computed tomography. The stent-grafting procedure was performed after informed consent had been obtained from each patient, and the procedure was approved by the institutional review board for human studies of Hiroshima University.
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Results
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All of the patients survived postoperatively, but 1 patient suffered a cerebral infarction and died of the cerebral infarction plus pneumonia during the follow-up period. Postoperative aortography revealed that there was no endoluminal leakage from the stent-graft into the distal arch aneurysm or pseudolumen in the descending aorta, except for 1 patient with minimal leakage from the distal portion of the stent-graft, which disappeared during the follow-up period. Postoperative computed tomographic scan and aortography revealed thrombosis of the distal arch aneurysm or a false lumen in the descending thoracic aorta by the endovascular stent-graft in the other patients. The coronary bypass grafts were all patent without stenosis in those patients undergoing concomitant coronary bypass grafting. The size of the graft ranged from 22 mm to 32 mm in diameter (Table 2). The selective cerebral perfusion time ranged from 52 to 86 minutes (mean, 68 minutes), and there was a range of 50 to 162 minutes (mean, 107 minutes) from the termination of the extracorporeal circulation to the closure of the chest. The total operating time ranged from 289 to 422 minutes (mean, 318 minutes). Left subclavian arterial reconstruction was performed in patients 4 and 5. Prosthetic bypass grafting from the right subclavian artery to the left subclavian artery was performed with a Dacron prosthesis (8-mm diameter) after termination of the extracorporeal circulation. Comparing these times with times for conventional total arch replacement, the mean hemostasis time and the total operating time were significantly shorter than corresponding times for conventional total arch replacement under selective cerebral perfusion. Blood loss through the chest tubes during the surgery and the postoperative period was also significantly lower in the stent-graft group than in the total arch replacement group (Table 3). Except for the 1 patient with a cerebral infarction, no other neurologic disorders were noted postoperatively.
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Comment
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Endovascular stent-grafting for aneurysms of the descending thoracic aorta is an innovative procedure, and it is less invasive than the standard prosthetic replacement. Mitchell and coworkers [1] reported the feasibility of endovascular stent-grafting for aneurysms of the descending thoracic aorta through a catheter inserted from the femoral artery. Slonim and associates applied stent-grafting for the treatment of aortic dissections, and they currently use this technique for the treatment of acute dissections with obliteration of the true lumen [2]. However, transfemoral endovascular stent-grafting is very difficult to perform in patients with abdominal aortic aneurysm and iliac arterial kinking [3]. In addition, we encountered many patients with distal arch aortic aneurysms that also required coronary artery bypass grafting. Therefore, we developed this endovascular stent-grafting procedure through the arch aorta for distal arch aortic aneurysms or chronic aortic dissections in the descending aorta, especially for those patients requiring simultaneous coronary artery bypass grafting. The procedure of endoluminal stent-grafting through the aortic arch was originally reported by Kato and associates [4]. Kato and colleagues performed transection of the arch aorta for insertion of the stent-graft. Kato and colleagues also reported an alternative method for distal arch aortic aneurysm repair combined with cervical branch bypass and endovascular stent-graft implantation through a prosthesis, without extracorporeal circulation [5]. This alternative method does not require extracorporeal circulation or aortic cross-clamping. However, we believe there is a risk of thromboembolism from intramural thrombi in the aneurysm during the insertion of the stent-graft under cardiac pulsation, and it is difficult to place the stent-graft in the proper location. Therefore, we modified Kato and colleagues’ original procedure and lessened the aortotomy. Most distal arch aortic aneurysms originate distally from the left carotid artery and are located just below the left subclavian artery. We can therefore introduce the stent-graft through a small incision in the aortic arch. Our method has several advantages, such as a decrease in bleeding from the small aortotomy, a shorter operative time, and no damage to the left recurrent nerve. It is easy to perform through a median sternotomy and does not require any special instruments except for a large sheath catheter and a Gianturco Z-stent. We had previously performed prosthetic replacement of distal arch aortic aneurysm combined with coronary arterial bypass grafting through left thoracotomy. In our experiences, this endoluminal stent-grafting was more easily performed than the conventional procedure through left thoracotomy, especially in patients requiring coronary artery bypass grafting.
Selective cerebral perfusion time was rather long in this initial series because we carefully performed endovascular stent-grafting. The proximal end of the stent-graft was sutured to the proximal aortic wall to prevent endoluminal leakage. Selective cerebral perfusion was initiated before hypothermic circulatory arrest and was continued for several minutes after initiation of rewarming to prevent cerebral embolism associated with endovascular stent-grafting.
However, this method has many limitations, especially for atherosclerotic aneurysms. If the aneurysm extends toward the right innominate artery, then it is impossible to introduce this stent-graft through an incision in the aortic arch. In addition, if the wall of the ascending aorta or the proximal arch aorta is severely atherosclerotic, there is a risk of thrombosis of the atheromatous plaque during the procedure.
In a type B aortic dissection, stent-graft coverage of the proximal entry point may be sufficient [6], with subsequent thrombosis of the false lumen as suggested by previous clinical experience in the operative graft replacements. We can also use this approach for acute type A aortic dissection with an intimal tear in the descending aorta, with concomitant replacement of ascending and arch aorta [7]. The risk of paraplegia is minimal in previous clinical experiences of endovascular stent-grafting [3]. Although the exact etiology of the paraplegia is multifactorial, the most important factor for paraplegia in open repair is the warm ischemic time during prosthetic replacement [8].
We encountered 1 patient who had a cerebral infarction with this procedure. This patient required the left femoral arterial perfusion because of atherosclerotic changes in the ascending aorta. The cerebral embolism in this patient might have occurred by retrograde perfusion or by aortic cross-clamping for the coronary bypass surgery. We principally performed ascending aortic perfusion or the right subclavian arterial perfusion for this stent-grafting procedure, except for this 1 patient.
Although our experiences are limited and the technique requires more improvement, we believe that this procedure can simplify surgery for distal aortic arch aneurysms and lessen both operative time and bleeding.
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References
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Mitchell R.S., Dake M.D., Semba C.P., et al. Endovascular stent-graft repair of thoracic aortic aneurysms. J Thorac Cardiovasc Surg 1996;111:1054-1062.[Abstract/Free Full Text]
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Slonim M.D., Nyman U., Semba C.P., Miller C.D., Mitchell R.S., Dake M.D. Aortic dissection. J Vasc Surg 1996;23:241-253.[Medline]
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Dake M.D., Miller D.C., Semb C.P., Mitchell R.S., Walker P.J., Liddell R.P. Transluminal placement of endovascular stent-grafts for the treatment of descending thoracic aortic aneurysms. N Engl J Med 1994;331:1729-1734.[Abstract/Free Full Text]
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Kato M., Ohnishi K., Kaneko M., Ueda T., Kishi D., Mizushima T. A new grafting-implanting method for thoracic aortic aneurysm or dissection with a stent-graft. Circulation 1996;94(Suppl II):188-193.
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Kato M., Kaneko M., Kuratani T., Horiguchi K., Ikushima H., Ohnishi K. New operative method for distal aortic arch aneurysm. J Thorac Cardiovasc Surg 1999;117:832-833.[Free Full Text]
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Accepted for publication April 20, 2000.
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Top
Abstract
Introduction
