Ann Thorac Surg 2007;84:1045-1047
© 2007 The Society of Thoracic Surgeons
How To Do It
An Extra Anatomic, Close Chest Approach to Manage an Aortic Arch Aneurysm in an 88-Year-Old Woman
Jacques Kpodonu, MD*,
Mark D. Peterson, MD, PhD,
Leonardo Aquiar-Lucas, MD,
Julio A. Rodriguez-Lopez, MD,
Edward B. Diethrich, MD
Department of Cardiovascular and Endovascular Surgery, Arizona Heart Hospital, Arizona Heart Institute, Phoenix, Arizona
Accepted for publication January 11, 2007.
* Address correspondence to Dr Kpodonu, Department of Cardiovascular and Endovascular Surgery, Arizona Heart Hospital and Institute, 2632 N 20th St, Phoenix, AZ 85006 (Email: jkpodonu{at}azheart.com).
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Abstract
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Repair of thoracic arch aneurysms in the octogenarian is associated with a high morbidity and mortality. In this report we describe a minimally invasive approach to repair and arch aneurysm using an endoluminal graft with an extrathoracic, extra anatomic de-branching of the arch vessels. The advantage of this technique includes avoidance of a median sternotomy, cardiopulmonary bypass, and circulatory arrest with a rapid postoperative recovery.
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Introduction
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Thoracic aortic aneurysms (TAA) are traditionally repaired with open surgical replacement with a tube graft [1]. Recent development of endograft therapy for the treatment of thoracic aortic aneurysms has been associated with a low morbidity and mortality [2]. Arch aneurysms have not been suitable for endovascular repair because of concerns about the supra-aortic vessels. Recently there have been isolated reports of de-branching techniques with the deployment thoracic endograft to treat proximal and distal arch aneurysm [3, 4]. We report a hybrid approach to treat an arch aneurysm without a median sternotomy, use of cardiopulmonary bypass, and circulatory arrest.
An 88-year-old woman was found to have a widened mediastinum on a routine chest roentgenogram. Computed tomographic scan of the chest demonstrated an arch aneurysm measuring 5.7 cm at the transverse aortic arch distal to the innominate artery takeoff (Figs 1A,
2A). Due to her advanced age, a planned repair of the arch aneurysm was performed using a hybrid approach.
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Fig 1. (A) Reformatted computed tomographic scan of the chest shows arch aneurysm distal to the inominate artery with largest diameter in the transverse arch. (B) Exclusion of the arch aneurysm with a Gore TAG excluder (W.L. Gore & Associates, Flagstaff, AZ) endograft, no endoleak noticed with arrow showing balloon expandable stent in the innominate artery.
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Fig 2. (A) Thoracic arch aneurysm distal to the innominate artery. (B) Bilateral low neck incisions are made to expose both common carotid arteries. (C) Arrow shows patent carotid-carotid bypass constructed with an end to side anastomosis with an 8 mm Hemashield graft to the right common carotid artery and a left end to end anastomosis to the left common carotid artery. (D) Carotid-carotid bypass with exclusion of arch aneurysm by thoracic endograft.
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Technique
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Bilateral low-neck incisions were made parallel to the sternocleidomastoid muscle (Fig 2B). Adequate mobilization of the common carotid artery was achieved, so a low-lying bypass graft could be tunneled beneath the sternal notch for cosmetic reasons. An 8-mm Dacron Hemashield graft (Boston Scientific Corp, Natick, MA) was tunneled beneath the sternal notch, and 5,000 units of heparin was given to the patient followed by proximal and distal cross clamps to the right common carotid artery and construction of end-to-side anastomosis using 5-0 polypropylene suture. Cross clamps were removed, the graft was clamped, and flow was reestablished to the right common carotid artery. The left common carotid artery was similarly mobilized up to its origin, proximal and distal cross clamps were applied, the artery was then transected close to the proximal clamp, and the distal end of the left common carotid artery was anastomosed to an 8-mm Dacron Hemashield graft (Boston Scientific Corp) as an end-to-end anastomosis. The proximal left common carotid artery was oversewn with a 4-0 transfixing suture. The cross clamps were removed and flow was subsequently established to the left common carotid artery through the newly created carotid-carotid bypass (Fig 2C).
Bilateral groin incisions were made to expose both common femoral arteries. Heparin was given to achieve an activated clotting time of greater than 200 secs. Under fluoroscopic guidance an 18 Gauge needle (Cook Group Inc, Bloomington, IN) was used to access both common femoral arteries. A soft tip glide wire (0.035 inch) was advanced to the arch of the aorta, and 9-French sheaths were placed in both groins. An arch aortogram was performed using a 5-French pigtail catheter through the left groin. After angiographic confirmation and under fluoroscopic surveillance a 40-mm x 20 cm Gore TAG excluder (W.L. Gore & Associates, Flagstaff, AZ) device was deployed just distal to the takeoff of the innominate artery (Fig 2D).
Completion angiogram showed complete exclusion of the arch aneurysm with moderate flow to both common carotid arteries due to partial obstruction of the ostium of the innominate artery by the flares of the endograft. An 8 mm x 37 mm balloon expandable express stent (Boston Scientific Corp) was deployed to the ostium of the innominate artery with a satisfactory angiographic picture and brisk flow to both carotid arteries with no endoleak. The sheaths and wires were removed, both common femoral arteries were repaired, and the patient was extubated in the operating room and was able to move all extremities. The patient had an uncomplicated hospital stay with no symptoms or signs of left upper extremity ischemia due to coverage of the left subclavian artery. The patient was discharged on postoperative day 3. Computed tomographic scan performed prior to discharge showed adequate flow through the bypass graft and both common carotid arteries (with no endoleak seen) and satisfactory position of the endograft (Fig 1B). Patient continues to do well at 5 months postoperatively.
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Comment
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Thoracic aneurysms with a diameter of less than 5 cm are associated with a 2-year patient survival of less than 30% [5]. If left untreated, most patients die from aneurysm rupture. The significant morbidity and mortality associated with open surgical repair of TAA has resulted in an increasing use of a less invasive and safer treatment modalities involving endovascular therapy. Endovascular treatment of TAA is associated with fewer procedure related complications, a shorter convalescence, and minimal neurologic sequelae [6].
Open graft replacement of arch aneurysms requires cardiopulmonary bypass, various degrees of hypothermia, and circulatory arrest, which increase the morbidity of the procedure. The use of a hybrid approach to treat aortic arch aneurysms can be satisfactorily performed with lower morbidity and mortality than a traditional open surgical approach, and this also affords high-risk patients the possibility of a less invasive repair. Variations of reconstruction of common carotid and subclavian arteries can be performed to provide adequate landing zones for the treatment of TAA [7].
The pre-sternal approach as described in our report avoids the bypass graft from being visible and subject to injury as in the pre-tracheal approach, and secondly it allows the possibility of the patient to undergo a tracheostomy in the near future. The disadvantage of this technique is that a sternotomy may be risky to perform if such a procedure was required in the future. Hybrid procedures using endografts with various combinations of supra-aortic de-branching procedures offer a less invasive approach to management of arch pathologies; however long-term data is needed to validate routine application in clinical practice.
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References
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- De Bakey ME, McCollum CH, Graham M. Surgical treatment of aneurysms of the descending thoracic aortaLong term results in 500 patients. J Cardiovasc Surg (Torino) 1978;19:571-576.[Medline]
- Parodi J, Palmaz J, Barone H. Transfemoral intraluminal graft implantation for abdominal aortic aneurysm Ann Vasc Surg 1991;5:491-499.[Medline]
- Buth J, Penn O, Tielbeek A, Mersman M. Combined approach to stent–graft treatment of an aortic arch aneurysm J Endovasc Surg 1998;239:329-332.
- Zhou W, Reardon ME, Peden EK, Lin PH, Bush RL, Lumsden AB. Endovascular repair of a proximal aortic arch aneurysm: a novel approach of supra-aortic debranching with antegrade endograft deployment via an anterior thoracotomy approach J Vasc Surg 2006;43:1045-1048.[Medline]
- Crawford ES, Denatale RW. Thoracoabdominal aortic aneurysm: observations regarding the natural course of the disease J Vasc Surg 1986;3:578-582.[Medline]
- Makaroun MS, Dillavou ED, Kee ST, et al. Endovascular treatment of thoracic aortic aneurysms: results of phase II multicenter trial of the Gore TAG thoracic endoprosthesis J Vasc Surg 2005;41:1-9.[Medline]
- Criado FJ, Clark NS, Arnatan MF. Stent graft repair in the aortic arch and descending thoracic aorta: 4 year experience J Vasc Surg 2002;36:1121-1128.[Medline]
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Abstract
Introduction
