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Ann Thorac Surg 2004;78:1256-1260
© 2004 The Society of Thoracic Surgeons
a Department of Cardiothoracic SurgeryVienna, Austria
b Department of Interventional Radiology, University of Vienna Medical School, Vienna, Austria
Accepted for publication March 8, 2004.
* Address reprint requests to Dr Czerny, Waehringer Guertel 18-20, Vienna, Austria A-1090
bypass{at}eunet.at
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Abstract |
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METHODS: Between October 2002 and September 2003, 5 patients (mean age, 79.5 years) presented with aortic arch aneurysms involving the origin of the left carotid artery. Treatment was made by sequential transposition of the left carotid artery into the brachiocephalic trunk and transposition of the left subclavian artery into the already transposed left common carotid artery with consecutive endovascular stent-graft placement into the aortic arch.
RESULTS: All patients survived both procedures. At completion angiography, a small type 1a endoleak was observed in 1 patient. After 1 week, the patient was readmitted for completion three-dimensional computed tomographic scan. The leak had already occluded spontaneously. Mean follow-up was 10 months (range, 4 to 16 months). At follow-up, all patients had normal computed tomographic scans with regular perfusion of the supra-aortic branches without any signs of endoleaks.
CONCLUSIONS: Combined repair of aortic arch aneurysms by sequential transposition of the supra-aortic branches with consecutive 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.
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Introduction |
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TopAbstractIntroductionPatients and MethodsResultsCommentReferences |
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Endovascular stent-graft placement has developed as a safe and effective treatment modality in various diseases of the descending aorta [7–11]. In case of involvement of the aortic arch, innovative vascular surgical approaches to maintain cerebral perfusion have been developed to enable safe and effective endovascular aneurysm repair [12–15]. However, these techniques require prosthetic replacement of supra-aortic branches. The avoidance of alloplastic material to maintain perfusion of the arch vessels may be particularly beneficial as alloplastic replacement of native blood vessels always involves the risk of infection with deleterious consequences [16]. In addition, the potential risk of clot formation on the artificial surface of an alloplastic vascular prosthesis is avoided by autologous transpositions of the arch vessels.
The aim of this study was to evaluate safety and efficacy of combined repair of aortic arch aneurysms by sequential transposition of the supra-aortic branches and endovascular stent-graft placement.
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Patients and Methods |
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Preoperative Evaluation and Surgical Approach
The original method was previously described in detail (see reference 17). Preoperative evaluation was made by multisclice computed tomographic scans to exclude major occlusive disease of the supra-aortic branches as well as the aorto-iliac axis for later arterial access of stent-graft insertion and also to be sure that a sufficient proximal neck of at least 2 cm along the lesser curvature of the aortic arch would be available after double transposition. We did not particularly focus on the competence of the circle of Willis. Intraoperative neuromonitoring was not applied in this particular subgroup of patients. Cerebral perfusion control was made by the arterial line in the right radial artery. In the initial 2 patients a median sternotomy approach was used and the pericardium was opened. The skin incision was extended parallel to the clavicula to gain sufficient access to the left subclavian artery. With the other 3 patients, we used an upper hemi-sternotomy approach instead of a complete sternotomy. The intraoperative situs is shown in Figure 1. After systemical heparinization with 5,000 international units, the left common carotid artery was dissected free and was clamped. The vessel was transversely divided. The proximal portion was closed with a 4-0 Prolene running suture (Ethicon, Inc, Somerville, NJ). Consecutively, the brachiocephalic trunk was partially clamped, longitudinally opened, and a side-to-end anastomosis was performed. Blood flow was reinstalled after flushing and removal of air. An analogous procedure was carried out between the left subclavian artery and the already transposed left common carotid artery in 2 patients (Fig 2). In the remaining patients, due to differences in maximum diameter between the left common carotid and the subclavian artery, a side-to-side anastomosis between the two vessels was chosen. In these cases, the left subclavian artery was ligated, in addition to being oversewn at its origin. After chest tube insertion, the wound was closed in layers.
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The Endofit endoluminal aortic stent-graft (Endomed, Phoenix, AZ) was used in 1 patient. This device consists of a single piece polytetrafluoroethylene graft, encapsulating circumferential Z-shaped nitinol rings along its length. There is no longitudinal support along the length of the graft as the Z-rings are not linked together. There is an uncovered Z-stent extending from the proximal end of the stent-graft to achieve fixation against the aorta, which is attached to the first Z-ring of the covered stent at only two crowns. The Endofit (Endomed) is supplied within a cartridge and not as a single preloaded stent-graft delivery system. The Endofit (Endomed) is currently redesigned as a single preloaded system. The device instructions currently recommend using the Cook Keller-Timmermans Introducer Set. The stent-graft is available in thoracic and aorto-monoiliac configurations (including custom made devices). It is available in straight and tapered designs with diameters ranging from 30 to 40 mm and lengths from 10 to 22 cm.
After a mean recovery of 17 days according to the individual functional status, patients were taken to the interventional radiologists' suite. After achievement of general anesthesia, arterial access was gained. In 4 patients a right common femoral artery access was chosen; in another patient the right common iliac artery was used. Initially a 5 French pigtail catheter was advanced through the right brachial artery into the aortic arch to reconfirm characterization of the morphology and the extent of the aneurysm (Fig 3). After systemic heparinization with 5,000 international units, an arteriotomy was performed, and the delivery system was advanced under fluoroscopic guidance until the tip reached the origin of the brachiocephalic trunk. Afterward, stent-grafts were inserted into the aortic arch.
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Results |
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TopAbstractIntroductionPatients and MethodsResultsCommentReferences |
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Stent-graft placement
Stent-graft placement was carried out after a mean time interval of 17 days. Vascular access was made through the right common femoral artery in 4 patients and through the right common iliac artery due to severe atherosclerotic calcification as well as severe tortuosity of the external iliac and the common femoral artery. All five endovascular procedures were completed uneventfully. The mean number of stent-grafts used was 2.5. In 1 patient, a small type 1a endoleak could be detected after stent-graft placement. After 1 week, the patient was readmitted for completion angiography. The endoleak had already closed spontaneously. One patient experienced postoperative bleeding from the right common iliac artery cannulation site and subsequently underwent re-exploration.
Mean hospital stay for both procedures (surgical and endovascular) was 16 days. Figure 4 depicts a three-dimensional computed tomographic scan after stent-graft insertion. A completion angiography confirming regular patency of the supra-aortic vessels as well as the stent-graft in regular position without any signs of an endoleak is shown in Figure 5.
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Comment |
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TopAbstractIntroductionPatients and MethodsResultsCommentReferences |
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The main advantage of this approach, besides being a less invasive procedure, is the avoidance of using alloplastic material to maintain perfusion of the arch vessels. As alloplastic replacement of native blood vessels always involves the risk of infection with deleterious consequences [16], this vascular surgical approach elegantly maintains supra-aortic perfusion extending a standard arterial transposition between the left sublclavian and left common carotid artery to the brachiocephalic trunk. In addition, the potential risk of clot formation on the artificial surface of an alloplastic vascular prosthesis was avoided. Interestingly, neither infection nor clot formation of thoracic aortic endovascular stent-grafts has been reported to date.
As this small series represents our initial experience with autologous sequential transposition and stent-graft placement, our experience with long-term durability of this procedure is limited. Several technical aspects have to be considered. Type 1 endoleak formation in this highly shear-stress exposed area has to be closely monitored. In addition, backbone fracture of the stent-graft must be kept in mind in this anatomically distinct position due to the severely curved pathway.
Postoperatively, it is likely that patients with endovascular stent-graft placement into the aortic arch are at increased risk of developing type 1 endoleaks as radial forces and severely curved pathways of vessels in combination with constant friction between the stent skeleton and the graft are more pronounced within the aortic arch than within the descending thoracic aorta. In addition, elongation and constriction in the longitudinal axis due to functional alterations during daily life may contribute to this chronic process [18, 19]. It remains to be seen in both locations (ie, the aortic arch and the descending thoracic aorta) if rigid or compliant grafts will perform better regarding graft-associated endoleaks and adaptation to morphologic changes of the aneurysm sac [20, 21].
In our experience this procedure can be performed safely without exposing these elderly patients (who are frail and have a diminished physiologic reserve) to substantial risk. However, some vascular surgical aspects have to be kept in mind. The aneurysm itself, due to its large size, approximates supra-aortic branches, thereby substantially facilitating vascular anastomoses. In addition, the supraclavicular extension of the incision enables mobilization of the supra-aortic branches up to an extrathoracic level, thereby enabling tension-free accomplishment of vascular transposition.
The side-to-end anastomosis between the brachiocephalic trunk and the left common carotid artery can be easily performed. However, the circumferential dissection of the left subclavian artery as well as the anastomosis between the left common carotid and the left subclavian artery might present some difficulties. In our experience, the left subclavian artery always adheres to the aneurysmal wall with more or less severe components of vessel wall inflammation resulting from the mechanical pressure arising from the aneurysm. Therefore careful dissection is mandatory to avoid opening the aneurysmal sac. In addition, maximum diameter between the left common carotid as well as the left subclavian artery may differ substantially. In 3 patients, we observed a twofold diameter of the left subclavian as compared with the left common carotid artery. In these situations, we decided to perform a side-to-side anastomosis to overcome this lumen incongruency.
This new approach itself is associated with further potential risks. Central manipulation of supra-aortic vessels may cause cerebral injury by embolization of atherosclerotic debris. Therefore a nontouch technique has to be applied whenever feasible. In addition, partial clamping of the innominate artery without any collateral cerebral perfusion may have significant morbidity if the duration of the anastomosis exceeds the time frame of cerebral ischemic tolerance. Incorrect re-routing of either the left common carotid artery or the left subclavian artery may result in kinking or compression of the vessel. Brisk manipulation of the stent-graft introducer within the aortic arch may lead to detachment of soft plaques or parietal thrombi with consecutive cerebral embolization. Incorrect estimation of the proximal neck length may lead to insecure proximal fixation of the stent-graft with early type 1a endoleak formation. Therefore it is essential to determine the length of the proximal neck along the lesser curvature of the aortic arch.
Nevertheless, combined approaches for arch aneurysms will extend the indications in this delicate anatomic region. Actually a variety of adjunctive techniques to enable stent-graft placement in patients with arch aneurysms is now available. Therefore, an extended application of these techniques will enable safe and effective treatment of this highly selected subgroup of patients with aortic aneurysms by avoiding conventional arch aneurysm repair in deep hypothermia and circulatory arrest.
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