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Ann Thorac Surg 2007;83:1158-1161
© 2007 The Society of Thoracic Surgeons

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New Technology

Hybrid Technique for Total Arch Repair: Aortic Neck Reshaping for Endovascular-Graft Fixation

^a Department of Cardiovascular Surgery, Azienda Ospedaliera Polo Universitario "Luigi Sacco," Milan, Italy
^b Department of Radiology, Azienda Ospedaliera Polo Universitario "Luigi Sacco," Milan, Italy
^c Laboratorio di Emodinamica e Radiologia Cardiovascolare Istituto Policlinico San Donato, San Donato Milanese, Italy

Accepted for publication July 6, 2006.

^_* Address correspondence to Dr Vanelli, Department of Cardiovascular Surgery, Azienda Ospedaliera Polo Universitario "Luigi Sacco" Via G.B. Grassi, 74 20157 Milan, Italy (Email: p.vanelli{at}hsacco.it).

	Abstract

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Purpose: Endovascular repairs of the aortic arch aneurysms require correct placement and an appropriate landing zone for fixation, which are not present in the majority of cases.

Description: We report a less invasive approach in 4 patients presenting an aortic arch aneurysm. We performed a hybrid procedure that is a combination of different techniques: a mid-sternotomy is performed, followed by transposition of the supra-aortic vessels, and neck reshaping with a proximal banding of the aortic arch. In particular, we banded the aorta to facilitate and optimize the endovascular fixation of the graft, reducing postoperative type-1 endoleaks.

Evaluation: The four procedures were uneventful with 1-day intensive care unit recovery. The postoperative and the 1-year follow-up CT scan did not reveal any endoleaks.

Conclusions: Hybrid technique, combined with banding of proximal aortic arch and endovascular grafting are an alternative technique to the conventional open aortic repair. A polyester cloth banding of the ascending and proximal aortic arch allow the neck reshaping of the aorta optimizing the fixation of the endovascular stent graft.

	Introduction

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The operative results and early clinical outcomes for total aortic arch repair have improved for several years, but still represent a high-risk operation with increased mortality and morbidity [1, 2], especially for high-risk patients. Endovascular stent graft treatment for aortic arch aneurysm has been recently introduced [3], but only selected cases are suitable for this technique [4] with questionable results [5]. In fact, endovascular stenting requires a satisfactory landing zone that guarantees fixation and sealing of the proximal part of the endograft. It avoids migration of the graft, very frequent in these patients with consequent endoleaks, while adapting to the distorted anatomy of the aortic arch. To optimize the deployment of the endovascular stent graft in these cases, different techniques of implantation have been described [6] with and without epiaortic arch debranching [7–9].

	Technology

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We evaluated the feasibility of performing a hybrid approach for the aortic arch repair, with a view to lower the surgical risk, minimize the invasiveness, and optimize the landing zone.

	Technique

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Patients
This study was approved by the ethics committee of our hospital. Each enrolled patient signed an informed consent form for the procedures and for the subsequent follow-up evaluations.

From January to June 2004, 3 male and 1 female patients were admitted to our hospital with an aneurysm of the aortic arch.

Preoperative Evaluation
Digital subtraction angiography, including cerebral four-vessel angiography and cerebral computed tomography was performed on all patients undergoing this procedure. The patency of the internal mammary arteries was detected by angiography. Iliac and femoral arteries were assessed for endovascular access suitability.

Surgical Technique
Standard general anesthesia was performed. Right and left radial arterial pressures were monitored simultaneously to assess adequate cerebral and upper limb perfusion. Transesophageal echocardiography was routinely used to assess whether atherosclerotic or calcified plaques were present in the ascending aorta or the aortic arch. In the third patient an aortic valvuloplasty was performed through a complete median sternotomy, including the replacement of the ascending aortic arch and its branches. Blood pressure was maintained at an average systolic pressure of 80 mm Hg by infusion of nitrates or administration of isoflurane. Systemic heparinization (3 mg/kg) was continued during implantation and anastomoses. After side clamping the ascending aorta, a double branched vascular prosthesis (14 x 7 x 7 mm Uni-Graft K-DV [Aesculap, Tuttlingen, Germany]) was sutured end-to-side in the mid-portion of the ascending aorta. The side clamp was then removed and the first limb of the prosthesis was anastomosed end-to-end to the innominate artery with a 5-0 monofilament running suture. The second limb was anastomosed to the left common carotid artery in the same fashion. The left subclavian artery was left open in the first patient for later embolization, because of aneurysm involvement. In the second case the left subclavian artery was anastomosed to a third limb of the prosthesis. We completed the procedures by banding the aorta with a vascular prosthesis (Hemashield Gold [Meadox Medical Inc, Oakland, NJ]), opened longitudinally then wrapped around the aorta, obtaining a mean outer diameter of 32 mm. This provided a cylindrical shaped, nonexpandable, and easily recognizable, proximal landing zone, which allowed for a better fixation of the endograft. This area should ideally be approximately 3 to 4 cm long and located distally to the aortic anastomosis of the branched vascular prosthesis. To visualize the proximal and distal parts of the banding (the landing zone) later, we marked each site with a radiopaque wire passed around the aorta (Figs 1–3).

View larger version (86K): [in this window] [in a new window]   Fig 1. Hybrid aortic arch repair procedure and anatomical map modified from Criado and colleagues [6]. Zone 0 (Z0): ascending aorta to innominate artery. Z1: after innominate artery to left carotid artery. Zone 3 (Z3): after left carotid artery to left subclavian artery. Zone 4 (Z4) from left subclavian artery to descending aorta. Transposition of the supra-aortic branches, banding of the aorta in the sectors Zone 1 (Z1) to Zone 2 (Z2) with a double branched vascular prosthesis cut longitudinally and sutured according to the size of the aorta, marking the proximal and distal part of the band for safe landing on Z1 of the vascular endograft.

View larger version (153K): [in this window] [in a new window]   Fig 2. Postoperative angiography of patient with a large aneurysm of the arch and displacement of the thoracic aorta. Two endografts were used to cover the aorta from Zone 1 (Z1) to Zone 4 (Z4). A sharp curve resulted without endoleak.

View larger version (168K): [in this window] [in a new window]   Fig 3. One-year angiographic computed tomography with 3-dimensional reconstruction: the "safe" landing zone is clearly visible between the markers (A–C) where the banding technique has been performed. The proximal part of the endograft (B) is standing inside the markers (A–C) without postoperative displacement.

Postoperative Evaluation
Angiographic control was done immediately after the endovascular placement to demonstrate the total exclusion of the aneurysm and the absence of the endoleak. The final result was evaluated by an angiographic computed tomography with 3-dimensional reconstruction before hospital discharge (Fig 3).

	Clinical Experience

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Patient 1
A 73-year-old man underwent aneurysmectomy of the descending aorta 30 years prior; that operation was complicated by lung empyema, which was later treated with a left superior lobectomy. He was well until June 2003 when he reported thoracic back pain. A standard anterior-posterior (AP) roentgenogram of the thorax showed an enlargement of the aortic arch. A CT scan confirmed an aneurysm of the mid-arch with the involvement of the left subclavian artery having a maximum transverse diameter of 91.5 mm. Preoperative evaluation revealed serious chronic obstructive pulmonary disease and chronic renal failure (creatinine 2.1 mg/dL). The calculated Euroscore was 12 with a logistic risk of 31.8%.

Patient 2
A 56-year-old man was evaluated for dysphonia with a standard anterior-posterior roentgenogram of the thorax that revealed a dilatation of the aortic arch. The subsequent CT scan showed an aneurysm of the aortic arch with a maximum transverse diameter of 68 mm in the distal section that involved the left subclavian artery, including a stenosis of the proximal left common carotid artery. He had a history of lung empyema, being previously operated on for abdominal aortic aneurysm, peripheral arterial obstruction disease, and right coronary stenosis. The calculated Euroscore was 8 with a logistic risk of 10.4%.

Patient 3
A 67-year-old woman was referred to us by another hospital. She had a severe regurgitation of the aortic valve and an aneurysm of the ascending aorta. A CT scan demonstrated an enlarged ascending aorta and the aortic arch exceeded 55 mm. The Euroscore was 9 with a logistic risk of 16%.

Patient 4
A 72-year-old man had received surgical resection of an abdominal aortic aneurysm 7 years prior. A thoracic-abdominal aortic aneurysm was detected by a CT scan with a proximal neck in the middle of the arch. He also presented with severe chronic pulmonary disease. The Euroscore was 9 with a logistic risk of 16%.

	Results

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The total ventilation time after surgical transposition of the supra-aortic vessels was a mean of 12.75 ± 2.2 hours. In the second patient, right coronary stent grafting (5 x 38 mm) (UltraTM, Guidant Inc, Santa Clara, CA), was also performed before the endovascular implantation. The third patient underwent an aortic valvuloplasty with cardiopulmonary bypass; his heart arrested before the supra-aortic transposition. In the fourth patient, four stent grafts were implanted to cover the aortic arch and the entire thoracic descending aorta (EndoFit [Endomed Inc, Phoenix, AZ]). The patients were immediately extubated after endovascular stent placement. All patients had a 1-day intensive care unit recovery. The first patient maintained a mean postoperative creatinine blood level of 1.6 mg/dL. All procedures were complication-free, without signs of transient or permanent neurologic events. The mean blood loss was 442.5 ± 43.5 mL. Only the first patient was transfused with 2 units of homologous blood. A postoperative CT scan did not reveal endoleak and showed normal positioning of the graft and perfusion of the arch and supra-aortic vessels.

Follow-Up
The mean follow-up period was 451.5 ± 102.7 days. All patients were well and reported a complete regression of pains or dysphonia. The CT scans were scheduled every 6 months for the first year, then once every other year thereafter. We were able to demonstrate the absence of endoleak, the exclusion of the aneurysms, the patency of the epiaortic vessels, and the endograft did not show any migration or fracture.

	Comment

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Hybrid techniques with revascularization of the epiaortic vessels and endovascular grafting were recently introduced for total aortic arch repair in high-risk patients who may not tolerate conventional open surgery. In particular, concomitant pathologies such as renal failure, severe chronic obstructive pulmonary disease, and old age increase mortality and morbidity. As a less invasive procedure, the hybrid aortic arch repair technique reduces the need of blood transfusions. The risk of cerebrovascular accidents is reduced because of the short partial ischemic times during the anastomoses of the epiaortic vessels. However, thromboembolism occurring in one or both vertebral arteries during side clamping and occlusion are potential risks, especially for patients with severe atherosclerosis. Bypassing the epiaortic vessels allows for a safer negotiation of the large bore, up to 26 F systems, needed to introduce the graft and stiff wires that may be responsible for the high incidence of cerebrovascular accidents reported in the literature regarding these procedures. An ideal endograft should be versatile enough to treat various types of aortic aneurysms; however, anatomical features of the aortic arch may jeopardize the implantation grafts with a high risk of persistent pressurization of the aneurysmal sac. In fact, despite oversizing of the endograft by 15% to 20%, and extra-anatomic bypass of the aortic branches, some authors [10] reported failure to obtain a secure proximal fixation in Zone 1 (Fig 1), resulting in a type 1 endoleak. New endovascular devices will be developed to meet these requirements, but at the moment the correct positioning and fixation of endografts in Zone 1 (Fig 1) are still significant challenges.

The aortic banding technique that we have presented offers many advantages for proximal graft fixation: (1) it creates a nonexpandable zone to land the endograft, (2) provides a long, linear, and cylindrical neck next to the aneurysm, (3) provides a radiopaque reference marker that can easily point out the landing zone, and (4) prevents further dilation of the aorta. The first two points are very important to reduce the risks of endoleak and migration of the graft. We used the full median sternotomy approach to transplant the epiaortic vessels, even if less invasive procedures of extra-anatomic bypass are described. We believe that the banding technique is most important to optimize the landing zone in the part of the aorta where the proximal part of the stent graft will be exposed to strong pulsatile stress, and it should always be performed in all patients. We think that with this approach the overall cerebrovascular accident occurrence is reduced when compared with traditional surgical methods. The banding technique could facilitate endovascular aortic arch repair providing an alternative means of treatment to the more conventional surgical repairs or dedicated endovascular procedures. The effectiveness and potential advantages of the hybrid aortic arch repair technique need to be validated in a larger patient sample with long-term follow-up.

	Disclosures and Freedom of Investigation

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The authors have no commercial association or sources of support that may pose a conflict of interest. In addition, the authors had full control of the study, methods used, outcome measurements, data analysis, and production of the written report.

	Acknowledgments

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The authors thank Michael Lawrence (F.R.S.H.) for editing the manuscript.

	Footnotes

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^Disclaimer 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.

	References

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1. Kazui T, Washiyama N, Muhammad BAH, Terada H, Yamashita K, Takinami M. Improved results of atherosclerotic arch aneurysm operations with a refined technique J Thorac Cardiovasc Surg 2001;121(3):491-499.[Abstract/Free Full Text]
2. Ueda T, Shimizu H, Hashizume K, Koizumi K, Mori M, Shin H, et al. Mortality and morbidity after total arch replacement using a branched arch graft with selective antegrade cerebral perfusion Ann Thorac Surg 2003;76(6):1951-1956.[Abstract/Free Full Text]
3. Inoue K, Hosokawa H, Iwase T, Sato M, Yoshida Y, Ueno K, Tsubok A, Tanaka T, Tamaki S, Suzuki T. Aortic arch reconstruction by transluminally placed endovascular branched stent graft Circulation 1999;100(19 Suppl):II316-II321.[Medline]
4. Criado FJ, Clark Nancy S, Barnatan Marcos F. Stent graft repair in the aortic arch and descending thoracic aorta: A 4-year experience J Vasc Surg 2002;36(6):1121-1128.[Medline]
5. Ivancer K, Dias N, Moktari A. Thoracic and dissecting aneurysmVascular and Endovascular Treatment of Atherosclerotic Aortic Arch Aneurysms. London: Biba Medical Ltd; 2004. pp. 221-225.
6. Criado FJ, Barnatan MF, Rizk Y, Clark NS, Wang C. Technical strategies to expand stent-graft applicability in the aortic arch and proximal descending thoracic aorta J Endovasc Ther 2002;9:1132-1138.
7. Schumacher H, Blocker D, Bardenheuer H, Hansmann J, Allenberg JR. Endovascular aortic arch reconstruction with supra-aortic transposition for symptomatic contained rupture and dissection: early experience in 8 high-risk patients J Endovasc Ther 2003;10:1066-1074.[Medline]
8. Kato T, Washiyama N, Muhammad BAH, Terada H, Yamashita K, Takinami M. Aortic arch aneurysm: treatment with extranaatomical bypass and endovascular stent grafting Cardiovasc Intervent Radiol 2002;25:419-422.[Medline]
9. Nienaber CA, Fattori R, Lund G, Dieckmann C, Wolf W, von Kodolitsch Yl. Nonsurgical Reconstruction of Thoracic Aortic Dissection by Stent-Graft Placement N Engl J Med 2004;340(20):1539-1545.
10. Tse L, MacKenzie K, Montreuil B, Obrand D, Steinmetz O. The proximal landing zone in endovascular repair of the thoracic aorta Ann Vasc Surg 2004;18:178-185.[Medline]

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