Ann Thorac Surg 2005;80:1475-1478
© 2005 The Society of Thoracic Surgeons
New technology
A Less Invasive Approach to Completely Repair the Aortic Arch
Thierry P. Carrel, MD
a
,
*
,
Dai-Do Do, MD
b
,
Jürgen Triller, MD
c
,
Jürg Schmidli, MD
a
a Clinic for Cardiovascular Surgery, Berne, Switzerland
b Division of Angiology, Berne, Switzerland
c Institute for Radiology, University Hospital Berne, Berne, Switzerland
Accepted for publication October 18, 2004.
* Address reprint requests to Dr Carrel, Clinic for Cardiovascular Surgery, University Hospital Berne, Berne, CH-3010 Switzerland (Email: thierry.carrel{at}insel.ch).
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Abstract
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PURPOSE: Surgical replacement of the aortic arch is an established procedure that requires cardiopulmonary bypass and deep hypothermic circulatory arrest. However, this approach is associated with major perioperative risks. The significant risks associated with conventional open repair of the thoracic aorta are the main argument for less invasive strategies.
DESCRIPTION: We present a less invasive surgical and endovascular approach that allows total exclusion of the aortic arch without the need for extracorporeal circulation, deep hypothermia, and circulatory arrest.
EVALUATION: All procedures were successful, and the patients recovered without neurologic, cardiac, or bleeding complications. Arteriography confirmed proper position of the stent graft and complete exclusion of the lesion at the end of the procedure. One patient had an endoleak type I and underwent successful additional retrograde stent-graft placement over the proximal landing zone 3 weeks after the initial procedure. Clinical follow-up (between 8 and 18 months) was fully uncomplicated in all patients. Computed tomographic scan at 6 months demonstrated complete exclusion of the arch lesion in all cases and did not reveal any endoleaks.
CONCLUSIONS: Assuming that technical refinements may improve all steps of the endovascular intervention, this combined approach may turn out to be the preferred therapeutic modality to repair aortic arch lesions in patients with multiple comorbidities who otherwise would not be candidates for a conventional operative repair. However, long-term observation is necessary to confirm the stability of this type of repair.
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Introduction
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Treatment of aneurysms, dissection, and other atherosclerotic lesions located in the aortic arch represent a continuing challenge. Until recently, surgical repair was the only effective treatment with substantial perioperative risk and mortality [1]. The early outcome has improved in recent years due to significant advances in perioperative care and surgical techniques (eg, better cerebral and myocardial protection). Transluminal endovascular stent-graft placement has been introduced as a promising alternative to repair aneurysms of the abdominal aorta and to a certain extent for those cases involving the descending thoracic aorta [2, 3]. This approach, deemed to be less invasive, requires safe landing zones of the normal aorta. The aortic arch with its curvature and origin of the supra-aortic vessels represents a location with special challenges for endovascular treatment.
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Technology
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We report on a promising combined surgical and endovascular approach that allows complete repair of the aortic arch.
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Technique
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The main potential advantage of this technique is that it does not require extracorporeal circulation. The procedure is performed in the operating room. An arterial perfusion cannula is inserted into the left and right radial arteries and a sheat into the femoral artery for pigtail catheter angiography. Transesophageal echocardiography is performed routinely to assist the delivery of the endovascular device. Surgical de-branching of the supra-aortic vessels is performed through complete or superior median sternotomy. Epicardial scanning and palpation help to exclude calcified or soft atherosclerotic lesions in the ascending aorta.
The ascending aorta, the aortic arch, and the supra-aortic branches are dissected free using a "minimal touch" technique to prevent embolization in case of severe arteriosclerosis. Heparin is given at a dosage of 100 IE/kg. The first surgical step includes the construction of a bifurcated bypass graft (Vaskutek Gelsoft [Vaskutek Ltd, Renfrewshire, UK]) from the ascending aorta to the innominate artery and the left common carotid artery. Both vessels are transected, oversewn at their aortic origin with a running polypropylene suture, and anastomosed to the corresponding limb in an end-to-end fashion. If perfusion pressure distal to the occlusion is superior to 60 mm Hg, no additional cerebral protection is used; if it is <60, a temporary shunt is inserted.
The left subclavian artery is either transposed into the left carotid artery or revascularized at the end of the procedure using an additional 8-mm graft (Fig 1).
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Fig 1. (A) Schematic representation and (B) intraoperative view after completion of full aortic arch stenting and revascularization of the supra-aortic vessels.
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Introduction of the stent-graft prosthesis was performed in an antegrade way (n = 2) through a separate 8 mm graft, which is anastomosed to the ascending aorta in an end-to-side fashion. After completion of the endovascular procedure, it is attached to the graft to the left subclavian artery. In 4 patients, the stent graft was introduced retrogradely through a femoral artery access. In all cases, adenosine was used to decrease systolic blood pressure to 50 mm Hg during stent-graft release in order to prevent uncontrolled displacement of the device.
The proximal landing zone is located in the most cranial part of the ascending aorta, occluding all supra-aortic branches. The Talent prosthesis (Medtronic, Minneapolis, MN) was used in 4 patients and the Endomed prosthesis (Endofit Inc, Phoenix, AZ) in 2.
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Clinical Experience
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During a 24-month period between 2001 and 2003, 215 patients received surgical treatment for diseases of the thoracic aorta and 16 received endovascular stent-graft of the descending aorta. Complete arch replacement was performed using conventional surgical technique (cardiopulmonary bypass, deep hypothermia, and antegrade cerebral perfusion) in 18 patients. We report 6 additional patients who presented either with complex previous aortic history (1 patient) or several comorbidities (5 patients) that were estimated to be a contraindication for conventional surgical repair, including cardiopulmonary bypass, deep hypothermia, and circulatory arrest. Five patients received complete aortic arch repair and in one partial (two-thirds) repair was performed using a combined surgical–endovascular approach. Computed tomography with angiography and three-dimensional reconstruction confirmed the feasibility of the procedure.
Lesions were large atherosclerotic aneurysms (n = 4), grade IV arteriosclerosis of the aortic arch with recurrent cerebral embolization and a small aneurysm (n = 1), and hypoplastic aortic arch combined to coarctation after multiple procedures since 1982.
All procedures were successful, and the patients recovered without neurologic, cardiac, or bleeding complications. Arteriography confirmed proper position of the stent graft and complete exclusion of the lesion at the end of the procedure. A 71-year-old woman underwent double coronary artery bypass grafting in the beating heart technique immediately after aortic arch repair. The left internal thoracic artery was grafted to the left anterior descending branch, and a saphenous vein graft was anastomosed to the right coronary artery. Computed tomographic scans were performed in every patient before discharge (Fig 2). One patient had an endoleak type I and underwent successful additional retrograde stent-graft placement over the proximal landing zone 3 weeks after the initial procedure.
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Fig 2. (A) Computed tomographic scan demonstrates an atherosclerotic aneurysm located in the mid-aortic arch. (B) Postoperative computed tomographic scan shows successful exclusion of the aortic arch aneurysm and complete covering of the atherosclerotic arch with the stent graft.
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Clinical follow-up (between 8 and 18 months) was fully uncomplicated in all patients. A computed tomographic scan at 6 months demonstrated complete exclusion of the arch lesion in all cases and did not reveal any endoleak.
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Comment
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The feasibility of stent-graft repair for aneurysms and dissection of the descending aorta has been documented, and some agreement exists regarding the major constraints necessary to assure success [2–5]. As thoracic aneurysms have become more ubiquitous, the demand for less invasive strategies has increased, especially for patients presenting with comorbidities or high-risk situations for cardiopulmonary bypass and deep hypothermia, or both. However, there are only a minority of patients presently suitable for total arch endovascular treatment, because stent-graft repair requires adequate proximal and distal landing zones. Different types of branched stent grafts to treat aortic arch aneurysms have been developed, but only partial repair of the arch was performed with intentional covering of the left carotid and subclavian artery origins so far [4, 5].
We have previously demonstrated some potential advantages of combined endovascular and surgical treatment of traumatic arch lesions [6]. This article shows that complete endovascular covering of the aortic arch after de-branching of all supra-aortic branches is also feasible. One of the major advantages of this technique lies in the fact that extracorporeal circulation and deep hypothermic circulatory arrest with their inherent risks are not required. Insertion of the stent graft to cover the aortic arch is performed after reconstruction and proximal oversewing of the supra-aortic vessels. In our opinion, this considerably reduces the risk of cerebral embolism during the endovascular steps.
Symptomatic atherosclerotic lesions of the aortic arch and aneurysms localized in the proximal and middle segments of the aortic arch will constitute the main lesions to be considered for this procedure. Minimizing the surgical approach may include de-branching of the supra-aortic branches through a combined cervical and superior sternotomy.
We have used intraoperative angiography to assess proper aneurysm exclusion in all cases. However, intravascular ultrasound may be considered as an appropriate alternative even though it would introduce an additional expensive technology, which is not necessary for treatment of such lesions.
Assuming that technical refinements may improve all steps of the endovascular intervention, this combined approach may turn out to be the preferred therapeutic modality to repair aortic arch lesions in patients with multiple comorbidities who otherwise would not be candidates for a conventional operative repair. However, long-term observation is necessary to confirm the stability of this type of repair.
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Disclosures and Freedom of Investigation
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There were no funds to perform this study and the technology (endovascular stent-graft material) was purchased like any other implant device. The authors had full control of the design of this observational prospective study, along with the methods used, outcome measurements, analysis of the data, and production of the written report.
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Disclaimer
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The Society of Thoracic Surgeons, the Southern Thoracic Surgical Association, and The Annals of Thoracic Surgery neither endorse nor discourage use of the new technology described in this article.
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References
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- Kazui T, Washiyama N, Muhammad BA, Terada H, Yamashita K, Takinami M. Improved results of atherosclerotic arch aneurysm operations with a refined technique J Thorac Cardiovasc Surg 2001;121:491-499.[Abstract/Free Full Text]
- Dake MD, Miller DC, Seimba CP, Mitchell RS, Walker PJ, Lindell RP. 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]
- Nienaber CA, Fattori R, Lund G, et al. Nonsurgical reconstruction of thoracic aortic dissection by stent-graft placement N Engl J Med 1999;340:1539-1545.[Abstract/Free Full Text]
- Criado FJ, Clark NS, Barnatan MF. Stent-graft repair in the aortic arch and descending thoracic aortaa 4-year experience. J Vasc Surg 2002;36:1121-1128.[Medline]
- Gorich J, Asquan Y, Siefarth H. Initial experience with intentional stent-graft coverage of the subclavian artery during endovascular thoracic aortic repairs J Endovasc Ther 2002;9(Suppl II):1139-1143.
- Carrel T, Do-dai D, Müller M, Triller J, Mahler F, Althaus U. Combined endovascular and surgical treatment of complex traumatic lesions of the thoracic aorta Lancet 1997;350:1146.[Medline]
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Abstract
Introduction
