Ann Thorac Surg 2005;79:1790-1792
© 2005 The Society of Thoracic Surgeons
How to do it
Assembly and Deployment of a Branched Arch Stent Graft Using the Transaortic Approach
Toshihiko Shibata, MDa,*,
Hidekazu Hirai, MDa,
Toshihiro Fukui, MDa,
Takanobu Aoyama, MDa,
Shigefumi Suehiro, MDa
a Department of Cardiovascular Surgery, Osaka City University Medical School, Osaka, Japan
Accepted for publication December 29, 2003.
* Address reprint requests to Dr Shibata, Department of Cardiovascular Surgery, Osaka City University Medical School, 1-4-3, Asahi-machi, Abeno, Osaka 545-8585, Japan
shibata{at}msic.med.osaka-cu.ac.jp
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Abstract
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Transaortic stent grafting is an alternative method for treating distal arch aneurysms. Total arch grafts are too bulky to be inserted into a sheath catheter during usual stent grafting methods. An assembling method that uses a chain stitch enables the deployment of any type of stent graft into the distal aorta without the need for a sheath catheter. We describe how to safely assemble and use a branched arch stent graft. We consider this method to be beneficial in selected cases involving extensive distal arch aneurysms or in patients with highly calcified aortas.
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Introduction
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Transaortic deployments of stent grafts have been conducted using a large sheath catheter [1, 2]. The chain stitch method for deploying a branched arch stent graft was described by Miyamoto and colleagues [3]. They demonstrated an arch stent graft bound to a curved tube by a chain stitch, but did not sufficiently detail the material and procedures used. In this study, we report further improvements in the deployment system using a chain stitch method.
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Technique
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The stent graft was prepared with a self-expandable Z stent (Cook, Bloomington, IL) and a 30-mm vascular prosthesis with four branches. The size of the graft was determined as 20% larger than the normal distal aorta measured with computed tomography. The anchors of the stent were removed with a soldering iron. The stent, which was 35 mm in diameter and 50 mm in length, was inserted into the distal areas of the arch graft and fixed with 5-0 monofilament sutures. To determine the length of the distal trunk of the graft, the length required for the distal landing zone of the stent graft must be added to the length between the left carotid artery and distal end of the aneurysm measured with angiography. A guidewire holder (Radifocus, Terumo, Japan) 40 cm in length, was inserted into the 22F of the ureteral catheter. The ureteral catheter was then inserted into the arch graft, and they were bound together with 1-0 silk to secure them before facilitation of the chain stitch. They were then bound together with a chain stitch from the tip of the ureteral catheter using a crochet needle (Fig 1). After completion of the chain stitching, the 1-0 silk stitches were removed (Fig 2).
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Fig 1. (A–D) The stent graft was bound to the ureteral catheter by a chain stitch using a crochet needle.
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Fig 2. A branched arch graft is shown after chain stitching. A ureteral catheter containing a guidewire holder was used inside the stent graft.
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Transaortic stent grafting using a branched arch graft was applied to a 76-year-old woman with a distal arch aneurysm in the left subclavian artery. Computed tomography showed a severely calcified aortic wall in the arch and distal aorta. The operation was performed with median sternotomy. A guidewire was inserted through the femoral artery into the aortic arch under transesophageal echocardiography guidance. Systemic perfusion was established by ascending aortic cannulation. The left axillary artery was explored, and end-to-side anastomosis using an 8-mm Dacron graft was undertaken for the cerebral perfusion. When the rectal temperature was 25°C, the aorta was transected between the carotid artery and the left subclavian artery, avoiding the calcifications. Selective cerebral perfusion (25°C) of the brachiocephalic artery and left common carotid artery was initiated with perfusion balloon catheters. The left subclavian artery was ligated near the aorta, after which the left axillary graft perfusion was initiated for cerebral perfusion. The guidewire was removed, and the stent graft was loaded into the descending aorta using the guidewire. After fully deploying the distal trunk of the branched stent graft to the predetermined length, the chain stitch was undone, allowing expansion of the stent. The stylet tube was then removed. The distal aortic stump was sutured to the graft body with a 4-0 monofilament suture buttressed with a felt strip. Systemic perfusion was reestablished from a perfusion branch of the graft. The left carotid and brachiocephalic arteries were anastomosed to the third and second branches of the arch graft, respectively. The proximal edges of the arch graft were then anastomosed to the ascending aorta, after which the cardiac perfusion was reestablished. The left axillary perfusion was discontinued, after which the graft was inserted into the mediastinum through the left thoracic cavity, and anastomosed with the first branch of the graft (Fig 3). Cardiopulmonary bypass time was 180 minutes, and the patient was extubated on postoperative day 1. No neurologic complications developed.
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Comment
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Stent grafts are commonly deployed with a sheath catheter, but the limited size of the stent grafts is often a problem with this method. The main advantage of the chain stitch method is that it does not require a sheath, which allows the use of any type of stent graft in transaortic stent grafting regardless of size and shape. Nomura and colleagues [4] used a polyvinyl tube for a cardiopulmonary bypass circuit as a sheath during a transaortic stent graft. This tube was not only large enough for the stent graft but it was also cost effective. In our experience, however, the surface of the polyvinyl tube does not slide smoothly when loading and deploying a stent graft. Moreover, because the branched arch graft is bulky, it is impossible to house it in a large sheath. Therefore, when using the sheath method for distal arch aneurysm surgery, two separated grafts would be required [1, 5]: a straight graft involving a metallic stent for the distal arch aneurysm, and a branched arch graft for reconstruction of the arch vessels. The chain stitch method, on the other hand, allows the use of a branched arch graft without separation.
Deployment of the stent graft must be both safe and easy. Atheromatous changes often exist in the aortic wall of patients with aortic aneurysms, and when a stent graft is roughly pushed into the aorta, atheromatous plaque might break off and enter the distal site. Moreover, the curvature of the distal arch is sometimes acute, especially in cases involving large aneurysms; therefore, insertion of the stent graft into the descending aorta is sometimes difficult even with a direct view into the distal aorta from the aortic stump. The guidewire method is greatly beneficial for smoothly inserting the stent graft into the predetermined position.
The deployment system described in this study requires insertion of a tube while binding with a chain stitch. Commercially available sheath catheters are so slippery that the stent graft often slips off easily even when bound tightly. Here, a nonslippery ureteral catheter was applied as a stylet tube when binding, but this catheter is too soft and flexible, and greater rigidity is required to improve preparation and deployment. Therefore, a guidewire holder, which matched the inner size of the ureteral catheter (22F), was inserted into the ureteral catheter to add sufficient rigidity. These guidewires run smoothly inside the holder. A guidewire set contains both a guidewire and holder, and so it is economically acceptable because guidewires are required in this deployment procedure.
The majority of distal arch aneurysms can be managed by a standard suture technique. However, we consider the method described here to be beneficial in selected cases involving extensive distal arch aneurysms or in patients with highly calcified aortas.
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References
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- Okada K, Sueda T, Orihashi K, Watari M, Ishii O. An alternative procedure of endovascular stent-graft repair for distal arch aortic aneurysm involving arch vessels. J Thorac Cardiovasc Surg. 2001;121:182–184
- Miyairi T, Kotsuka Y, Ezure M, et al. Open stent-grafting for aortic arch aneurysm is associated with increased risk of paraplegia. Ann Thorac Surg. 2002;74:83–89[Abstract/Free Full Text]
- Miyamoto S, Hadama T, Anai M, Sako H, Shigematsu O. Stented elephant trunk method for multiple thoracic aneurysms. Ann Thorac Surg. 2001;71:705–707[Abstract/Free Full Text]
- Nomura F, Mukai S, Fumimoto Y, Shimazautsu K, Ihara K. Reliable and cost-effective system for surgical stent graft insertion. Ann Thorac Surg. 2000;70:2171–2172[Abstract/Free Full Text]
- Uchida N, Ishihara H, Sakashita M, Kanou M, Sumiyoshi T. Repair of the thoracic aorta by transaortic stent grafting (open stenting). Ann Thorac Surg. 2002;73:444–449[Abstract/Free Full Text]
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Abstract
Introduction
