Ann Thorac Surg 2007;83:1535-1536
© 2007 The Society of Thoracic Surgeons
Case Reports
One-Stage Repair With a New Integrated Stent-Dacron Prosthesis for Type B Aortic Dissection
Aristotelis Panos, MDa,*,
Spyros Kalakonas, MDa,
Elefterios Chouliaras, MDa,
Gregory Khatchatourov, MDb
a Clinic for Cardiac Surgery, Hygeia Hospital, Athens, Greece
b Clinic Cecil, Lausanne, Switzerland
Accepted for publication October 20, 2006.
* Address correspondence to Dr Panos, Rue de l’ Athénée 30, Geneva, 1206 Switzerland (Email: a.panos{at}bluewin.ch).
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Abstract
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We describe one-stage repair for a dilated chronic type B aortic dissection in a 55-year-old man by means of a new integrated stent-graft–Dacron prosthesis (Jotec, Hechingen, Germany).
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Introduction
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The one-stage repair was performed through a partial upper sternotomy and under moderate hypothermia and circulatory arrest. The distal aortic arch was opened and the endovascular part of the prosthesis was deployed. The Dacron soft part of the prosthesis (Jotech, Hechingen, Germany) was sutured distally to the ostium of the left subclavian artery. Perioperative angiography demonstrated a well deployed prosthesis and the exclusion of the aneurysm. The operation and recovery were uneventful.
The preferred treatment for type B aortic dissection remains medical. The endovascular approach for type B acute or chronic aortic dissection is under evaluation. Generally surgical intervention for type B aortic dissection has been reserved for complications such as aneurysmal expansion of the false lumen or end organ malperfusion. Combined approaches for the treatment of type A dissection with surgical repair of the ascending aorta and transluminal stenting of the descending aorta have been already reported [1], aiming to associate the advantages of both techniques.
A 55-year-old man suffered an acute type B aortic dissection 8 months before operation, and managed medically with a good outcome. A follow-up computed tomographic scan showed an aneurysmal enlargement of the proximal portion of the false lumen up to 60 mm in diameter, 2 cm distally to the ostium of the left subclavian artery (Fig 1).
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Fig 1. Reconstructed image of the preoperative computed tomographic scan showing a chronic type B aortic dissection complicated with an aneurysmal formation distally to the ostium of the left subclavian artery.
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The E-vita open (Jotec Inc, Hechingen, Germany) is Communauté Européenne marked and available for implantation on the market. It consists of a polyester fabric with a flexible nitinol wire skeleton fixed on the outer aspect of the fabric with polypropylene sutures. At the proximal end, a woven vascular Dacron prosthesis of 7 cm length is incorporated continuously to the stent-graft prosthesis, allowing for direct replacement of the aortic arch without an additional anastomosis, like in classical elephant trunk operations by simply pulling back the invaginated Dacron part of the prosthesis at its sewn suture sling into the arch position. Stent-graft release is realized as a pull back system introduced over the previously placed guidewire from the femoral artery.
The patient gave his informed consent for the operation. Under general anesthesia, a 0.35-stiff backup Meier guidewire (Boston Scientific Corp, Boston, MA) was placed through the nondissected right femoral artery into the distal aortic arch under roentgenogram control. This allows the guide to be placed in the true lumen. A small upper sternotomy was performed, and cardiopulmonary bypass was installed through the right axillary artery and the right femoral vein. The patient was cooled to a rectal temperature of 27°C. During cooling the aortic arch and neck vessels were prepared for control. At 27°C the flow rate of the cardiopulmonary bypass was decreased. The aorta was cross clamped proximal to the left subclavian artery. During this period of systemic circulatory arrest, the brain was continuously perfused through the right axillary artery to a rate flow of 12 mL/kg/min. The distal aortic arch was incised obliquely on its anterior aspect between the left carotid and subclavian artery. A 28-mm diameter stent was deployed over the wire into the descending aorta under direct vision distal to the origin of the left subclavian artery. The incorporated vascular prosthesis was pulled back toward the aortic arch; it was cut and sewn in an inlay fashion with two continuous sutures of polypropylene 5-0 just distally to the origin of the left subclavian artery. The aortic arch incision was closed. The systemic perfusion was resumed and the clamp on the aortic arch was released. On completion of the procedure, a digitalized angiographic scan showed a good deployment of the stent and a normal perfusion of the splanchnic and both renal arteries. The operation was completed in the usual way after lower body circulatory arrest of 50 minutes, an aortic cross clamp time of 110 minutes, and a total cardiopulmonary time of 210 minutes.
The postoperative course was uneventful. The patient was discharged 7 days later. The follow-up computed tomographic scan showed a complete exclusion of the aortic aneurysm and thrombosis of the false lumen up to the distal extremity of the endograft (Fig 2).
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Fig 2. Sagittal image of the postoperative computed tomographic scan demonstrating the deployed stent-graft and the excluded aortic aneurysm. Note that the graft is sutured just distally to the origin of the left subclavian artery through its integrated Dacron prosthesis (white line).
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Comment
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Type B aortic dissection is usually treated conservatively. Surgery is considered when medical treatment fails. Despite improved surgical techniques, operative mortality remains high (ie, between 25% and 50%) [2]. Several studies suggest that the endovascular treatment may reduce postoperative morbidity and mortality rates, as well hospital stay [3]. However complications resulting from these endovascular procedures, such as retrograde dissection, stent-graft migration, structural deteriorations, and endoleaks may lead to enlargement of the aortic aneurysm with catastrophic sequelae [4]. Stent-graft migration is an important cause of endoleaks at the proximal fixation site, even in devices with hooks and barbs at this site [5]. Our patient showed a fast enlargement of the proximal false lumen. Deploying a stent-graft in such an unstable proximal landing zone could compromise the long-term results for this patient. The one-stage repair with this integrated prosthesis offers a stable fixation of the stent-graft through its integrated vascular Dacron prosthesis without compromising the patency of the left subclavian artery by overstenting it. Indeed in a recent study, Schoder and colleagues [6] reported 8.6% serious neurologic complications after overstenting the left subclavian artery. Follow-up computed tomographic scan at 1 month showed that the false lumen was completely thrombosed and the aneurysm was excluded (Fig 2). The insertion and the fixation of the stent-graft were accomplished in 50 minutes during the period of systemic circulatory arrest. Deploying the stent-graft within the true lumen of the descending aorta was facilitated by direct vision from the open arch and by introducing it over the previously inserted wire. The chosen diameter of the stent-graft should correspond to the true lumen of the dissected aorta. Any oversizing should be avoided to prevent the rupture of the fragilized true lumen. The incorporated vascular Dacron prosthesis is not pre-clotted and has to be coagulated before becoming blood proof. One can imagine that when this prosthesis is intended to replace the totality or part of the aortic arch, it has to be sprayed with biological glue before use. A fabric modification toward a low porosity polyester graft would be strongly appreciated. Although long-term results are missing, we do believe that the integration of the classic open technique with the stent-graft technology opens a promising method toward intended single-stage therapy of complex thoracic aortic disease.
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References
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- Panos A, Kalangos A, Christofilopoulos P, Khatchatourian G. Combined surgical and endovascular treatment of aortic type A dissection Ann Thorac Surg 2005;80:1087-1090.[Abstract/Free Full Text]
- Stone C, Borst H. Dissecting aortic aneurysmIn: Edmunds Jr LH, editor. Cardiac surgery in the adult. New York: McGraw-Hill; 1997. pp. 1153-1157.
- Najibi S, Terramani TT, Weiss VJ, McDonald MJ, Lin PH, Redd DC. Endoluminal versus open treatment of descending thoracic aortic aneurysms J Vasc Surg 2002;36:732-737.[Medline]
- Alric P, Hinchliffe R, Wenham P, Whitaker S, Chuter T, Hopkinson B. Lessons learned from the long-term follow-up of a first generation aortic stent graft J Vasc Surg 2003;37:367-373.[Medline]
- Harris P, Vallabhaneni S, Desgranges P, Becquemin JP, vanMarrewijk C, Laheij RJF. Incidence and risk factors of late rupture, conversion, and death after endovascular repair of infrarenal aortic aneurysms: The EUROSTAR experience J Vasc Surg 2000;32:739-749.[Medline]
- Schoder M, Grabenwöger M, Hölzenbein T. Endovascular repair of the thoracic aorta necessitating anchoring of the stent graft across the arch vessels J Thorac Cardiovasc Surg 2006;131:380-387.[Abstract/Free Full Text]
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Abstract
Introduction
