Ann Thorac Surg 2007;84:e1-e3
© 2007 The Society of Thoracic Surgeons
Case Reports
Endovascular Thoracic Aortic Aneurysm Repair With Concomitant Myocardial and Carotid Revascularization
Keshava Rajagopal, MD, PhDc,
Brian Lima, MDc,
J. Kevin Harrison, MDb,
Madhav Swaminathan, MBBSa,
Richard L. McCann, MDc,
G. Chad Hughes, MDc,*
a Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
b Department of Medicine, Duke University Medical Center, Durham, North Carolina
c Department of Surgery, Duke University Medical Center, Durham, North Carolina
Accepted for publication March 13, 2007.
* Address correspondence to Dr Hughes, Box 3051, Duke University Medical Center, Durham, NC 27710 (Email: gchad.hughes{at}duke.edu).
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Abstract
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A 73-year-old woman presented with a large saccular aneurysm involving the distal aortic arch. Preoperative aortography and cardiac catheterization revealed left main coronary artery and left common carotid artery stenoses. Concomitant coronary artery bypass grafting to the left anterior descending and first diagonal arteries, ascending aorta-to-left common carotid artery bypass grafting, and endovascular thoracic aortic aneurysm repair with antegrade stent-graft deployment and intentional left subclavian artery coverage were performed.
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Introduction
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The simultaneous treatment of various coexistent cardiovascular diseases is increasingly common. In addition, the use of hybrid, open-endovascular techniques is also increasing in popularity. We present a case of coexistent coronary artery disease, carotid artery stenosis, and thoracic aortic aneurysm, which were treated in a single operation by a hybrid approach.
A 73-year-old woman with hypertension, hyperlipidemia, and tobacco abuse presented with exertional dyspnea and cough without hoarseness. As part of her work-up, a computed tomographic scan was obtained demonstrating a 3.4-cm saccular distal arch aneurysm arising adjacent to the left subclavian artery (LSA) (Fig 1A), and severe aortoiliac occlusive disease. The proximal landing zone (PLZ) between the aneurysm and left common carotid artery (LCCA) ostium was < 2 cm, precluding standard endovascular repair. Consequently a hybrid approach was chosen to create PLZ. Preoperative electrocardiography noted evidence of a previous anterior myocardial infarction. Echocardiography demonstrated normal left ventricular systolic function, mild left ventricular diastolic dysfunction, and no associated valvular abnormalities.
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Fig 1. (A) Preoperative computed tomographic scan showing axial cross-section demonstrating the saccular thoracic aortic aneurysm (arrow). (B) Intraoperative photograph of the aneurysm as seen from the surgeon’s view (arrow). (C) Intraoperative marker aortogram illustrating antegrade filling of the aneurysm (arrow). (D) Intraoperative completion aortogram illustrating successful exclusion of the aneurysm sac with absence of antegrade flow into aneurysm (very faint, late retrograde filling of sac still present; arrow). (E) Three-dimensional reconstruction; computed tomographic scan at 12-month follow-up. (LCCA = left common carotid artery.)
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Because of the presence of coronary artery disease risk factors, as well as clinical criteria suggesting intermediate clinical risk for adverse postoperative cardiovascular outcomes [1], coronary angiography was performed (class IIa recommendations [1]). This revealed a 75% ostial left main coronary artery lesion, tandem 50% first diagonal artery (D1) stenosis, and a 75% left anterior descending coronary artery (LAD) lesion; a dominant right coronary artery without significant disease supplied most of the left circumflex territory. Concomitant aortography demonstrated a 95% proximal LCCA stenosis and confirmed a saccular distal arch aneurysm adjacent to the LSA. The coronary and LCCA lesions satisfied accepted criteria for surgical intervention [2, 3], particularly in the setting of planned major aortic surgery, for which both open and endovascular approaches carry appreciable risks of perioperative myocardial infarction and stroke.
Planned treatment included:
- 1 Coronary artery bypass grafting of the LAD and D1. In light of a requirement for LSA coverage with endovascular aneurysm repair, a free left internal mammary artery (LIMA) graft, which has equivalent patency to the pedicled LIMA [4] was chosen for the LAD.
- 2 The ascending aorta-to-LCCA bypass would both augment LCCA blood flow and eliminate an atheroembolic source. In addition, this would partially "de-branch" the arch, creating PLZ for endovascular repair.
- 3 The endovascular stent-graft placement was made to treat the saccular aneurysm with planned coverage of both the LCCA and LSA to ensure adequate PLZ. Intentional coverage without revascularization of the LSA is generally well-tolerated [5] with distal LSA flow derived from retrograde left vertebral artery flow. Antegrade stent-graft deployment across the aortic arch [6] was planned secondary to aorto-iliac occlusive disease.
A median sternotomy was performed and systemic heparinization was instituted. Arterial and venous cannulations for cardiopulmonary bypass were made through the right axillary artery and right atrium, respectively. The LIMA was harvested and divided for later use as a free graft. Cardiopulmonary bypass was initiated with cooling to 32°C to provide additional cerebral protection during arch de-branching. The large saccular aneurysm involving the distal arch was easily visualized (Fig 1B). The ascending aorta was cross clamped and the heart was arrested. Distal coronary anastomoses were performed first, using the free LIMA to the LAD and a saphenous vein graft (SVG) to D1. Next, using a single clamp technique, a 10-mm Dacron graft (DuPont, Wilmington, DE) (with a 10-mm proximal side graft sewn to it) was anastomosed to the ascending aorta. The proximal anastomosis of the SVG was also performed at this time. The aortic cross-clamp was then released. The LCCA was clamped and transected. The distal end of the Dacron graft was anastomosed end-to-end to the distal LCCA; the proximal stump was oversewn. Finally, the proximal anastomosis of the LIMA was performed to the hood of the proximal anastomosis of the SVG. Rewarming was completed, and the patient was weaned from cardiopulmonary bypass. Total cardiopulmonary bypass and cross-clamp time were 126 and 46 minutes, respectively.
Next, a 180-cm 0.035" Glidewire (Terumo Medical Corp, Somerset, NJ) was passed antegrade into the descending aorta through a 9-French sheath in the 10-mm side graft of the bypass graft to the LCCA. This wire and sheath were respectively exchanged for an Amplatz Super Stiff wire (Boston Scientific Corp, Natick, MA) and a 22-French Gore introducer sheath (W. L. Gore Corp, Flagstaff, AZ), which were advanced into the ascending aorta. A-5 French sheath was placed percutaneously in the left common femoral artery, and a marker pigtail catheter was advanced retrograde over a wire into the ascending aorta. A marker aortogram was shot, delineating the location of the aneurysm and providing a road map for endograft placement (Fig 1C). A 34 mm x 15 cm Gore TAG prosthesis (W.L. Gore Corp) was deployed antegrade across the aortic arch, with the PLZ just distal to the innominate artery ostium. Completion aortography demonstrated excellent flow in the bypass graft to the LCCA, and exclusion of the aneurysm with no antegrade filling of the aneurysm sac (Fig 1D). The side graft was then transected and oversewn, and anticoagulation was reversed. Closure was completed. There were no immediate complications.
The patient’s postoperative course was notable for a transient ischemic attack on postoperative day 1, manifested with left upper extremity weakness and left-sided neglect. This resolved within 30 minutes without residual deficits. A head computed tomographic scan was negative, and she was treated with aspirin and dipyridamole without further events. The cause was presumed atheroemboli from either her severely diseased aortic arch or a known 50% to 69% right internal carotid artery stenosis (by preoperative duplex ultrasonography). She was discharged home on postoperative day 11 in good condition, and she was neurologically intact. At her 12-month follow-up she is asymptomatic from both cardiovascular and neurologic standpoints. Follow-up computed tomographic scan demonstrates a widely patent bypass graft to the LCCA, thrombosis and shrinkage of the aneurysm sac, and no endoleak (Fig 1E).
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Comment
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In reviewing the literature, we believe this case represents the first report of a hybrid approach to treat coexistent coronary artery disease, cerebrovascular disease, and thoracic aortic aneurysmal disease. For a variety of aortic diseases, such approaches are gaining acceptance and popularity. Several specific preoperative and operative considerations pertinent to the treatment of thoracic aortic aneurysmal disease with coexistent atherosclerotic occlusive disease requiring revascularization must be carefully contemplated as illustrated by this case.
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References
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- Scanlon P, Faxon D, Audet A, et al. ACC/AHA guidelines for coronary angiography: executive summary and recommendations. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Coronary Angiography) developed in collaboration with the Society for Cardiac Angiography and Interventions Circulation 1999;99:2345-2357.[Free Full Text]
- Eagle K, Guyton R, Davidoff R, et al. ACC/AHA 2004 guideline update for coronary artery bypass graft surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery) Circulation 2004;110:e340-e437.[Free Full Text]
- Executive Committee for the Asymptomatic Carotid Atherosclerosis Study Endarterectomy for asymptomatic carotid artery stenosisExecutive Committee for the Asymptomatic Carotid Atherosclerosis Study. JAMA 1995;273:1421-1428.[Abstract/Free Full Text]
- Ascione R, Underwood M, Lloyd C, et al. Clinical and angiographic outcome of different surgical strategies of bilateral internal mammary artery grafting Ann Thorac Surg 2001;72:959-965.[Abstract/Free Full Text]
- Gorich J, Asquan Y, Seifarth H, et al. Initial experience with intentional stent-graft coverage of the subclavian artery during endovascular thoracic aortic repairs J Endovasc Ther 2002;9(Suppl 2):II39-II43.[Medline]
- Diethrich E, Ghazoul M, Wheatley G, et al. Great vessel transposition for antegrade delivery of the TAG endoprosthesis in the proximal aortic arch J Endovasc Ther 2005;12:583-587.[Medline]
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G. C. Hughes, C. F. Sulzer, R. L. McCann, and M. Swaminathan
Endovascular Approaches to Complex Thoracic Aortic Disease
Seminars in Cardiothoracic and Vascular Anesthesia,
December 1, 2008;
12(4):
298 - 319.
[Abstract]
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Abstract
Introduction
