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Original Articles: Cardiovascular

Combined Surgical and Endovascular Repair of Complex Aortic Pathologies With a New Hybrid Prosthesis

^a Department of Cardiovascular Surgery, Hospital Hietzing, Vienna, Austria
^b Department of Radiology, Hospital Hietzing, Vienna, Austria
^c Department of Anesthesiology, Hospital Hietzing, Vienna, Austria

Accepted for publication July 3, 2007.

^_* Address correspondence to Dr Gorlitzer, Hospital Hietzing, Wolkersbergenstr 1, Vienna, A-1130, Austria (Email: michael.gorlitzer{at}wienkav.at).

	Abstract

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Background: We evaluated the application of a new combined surgical and endovascular technique for the treatment of thoracic aortic aneurysms and dissections. The technique is used to treat extensive aortic disease by a single-stage procedure. Surgical outcomes and follow-up data are summarized and analyzed.

Methods: Between August 2005 and December 2006, 7 patients (2 women), aged 62 ± 11 years, with aortic pathologies (5 dissections, 2 aneurysms) underwent replacement of the ascending aorta and the aortic arch and simultaneous stent graft implantation into the descending aorta. The stent graft used was the E-vita open endoluminal stent graft (Jotec Inc, Hechingen, Germany), which was implanted using the technique of circulatory arrest and moderate hypothermia with selective antegrade cerebral perfusion. The stent graft was deployed under visual guidance through the open aortic arch into the true lumen.

Results: Intraoperative antegrade stenting of the descending aorta combined with the distal ascending aorta and aortic arch repair was performed successfully in all patients. The survival rate was 100%. One patient had a postoperative neurologic deficit but recovered completely. Four patients had fully thrombosed perigraft spaces within 11 days, whereas 1 patient showed complete obliteration of the false lumen at the 3-month control.

Conclusions: The combined surgical and endovascular technique described in this report proved feasible for the treatment of extended aortic lesions. It serves as an additional option for aortic repair in a single-stage method and is associated with no elevated risk for the patient.

	Introduction

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Extensive disease of the thoracic aorta that involves the ascending aorta, the aortic arch, and the descending aorta remains a challenge for the surgeon. In 1983, Borst [1] described the elephant trunk operation, which facilitates surgical repair of aneurysms involving the aortic arch and the descending aorta. This staged repair method includes two major surgical procedures, one through a median sternotomy and the second through a lateral thoracotomy, thereby increasing the cumulative risk [2]. A new combined approach for the treatment of aortic dissection uses replacement of the ascending aorta and the aortic arch, along with antegrade stenting of the descending aorta, and allows single-stage repair through median sternotomy. This report summarizes the preliminary results of this combined surgical and endovascular treatment.

	Patients and Methods

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Patients
Between August 2005 and December 2006, 7 patients (5 men, 2 women) with aortic pathologies (5 dissections, 2 aneurysms), monitored by computed tomography angiography (CTA), underwent replacement of the ascending aorta and the aortic arch and simultaneous implantation of a stent graft into the descending aorta. Informed consent was obtained from all patients, and the study was approved by the Ethics Committee.

The patients were a median ± SD age of 62 ± 10.8 years (range, 40 to 74 years). Four had a type A aortic dissection: two of the chronic type and two of the acute type. One patient with type B dissection presented with retrograde dissection of the aortic arch and ascending aorta, with signs of contained rupture, increasing chest pain, and pericardial effusion. The average extent of the descending aortic aneurysms was 7.25 cm (range, 5.9 to 8 cm). A 40-year-old woman with Marfan syndrome had undergone aortic root reconstruction using the Cabrol technique (replacement of the proximal ascending aorta after acute Stanford type A dissection) and revisited the outpatient clinic because of recurring chest pain. The CT scan revealed chronic Stanford type A dissection originating from the distal anastomosis of the prosthesis within the ascending aorta and extending up to the iliac arteries. The maximum diameter of the aorta was 5.9 cm [3].

At the time of operation, 1 patient was hemodynamically unstable, and the remaining patients were stable when they underwent operation. Significant comorbidities were present: 5 patients had hypertension, 2 had chronic renal failure, and 1 had diabetes mellitus. Concomitant cardiac pathologies included coronary artery disease in 1 patient and aortic valve disease in another. All patients had chest or back pain at the time of the intervention, and 3 had dyspnea. The zone of primary entry tear was from dissected aortic pathologies in the ascending aorta in 3 patients and in the aortic arch in 1 patient.

Endovascular Prosthesis
The commercially available E-vita open endoluminal stent graft (Jotec Inc, Hechingen, Germany) was used. It consists of a single polytetrafluoroethylene graft encapsulating circumferential Z-shaped nitinol rings along its length and a 70-mm Dacron prosthesis at the proximal end (Fig 1). Because the Z-rings are unlinked, the inner lumen of the vessel is highly flexible. A spiral CTA of the thoracic aorta was performed preoperatively to assess the extent of the aneurysm and dissection and to determine the appropriate size of the stent graft in each case.

View larger version (32K): [in this window] [in a new window]   Fig 1. The E-vita open endoluminal stent graft (Jotec Inc, Hechingen, Germany). (Left) Deployed stent graft with its Dacron prosthesis at the proximal end. (Right) Closed device with stiff guidewire.

Technique
Cardiopulmonary bypass was created using the right axillary artery and the right femoral vein or the right atrium. Median sternotomy was performed. The patients were cooled to a core temperature of 25°C. During the process of body cooling, the aortic arch and neck vessels were dissected, and the left ventricle was vented through the right superior pulmonary vein or the apex. After the target temperature of 25°C had been achieved, the cardiopulmonary bypass was discontinued.

The ascending aorta and the concavity of the aortic arch was resected to the level of the left subclavian artery. All patients received retrograde cold blood cardioplegia. Elective bilateral antegrade cerebral protection was achieved with 10 mL/kg/min of cold blood perfusion by clamping the innominate artery and direct cannulation of left carotid artery [4]. Hemispheric oxygen saturation was measured during brain perfusion by a near-infrared spectrophotometric device (NIRO 200; Hamamatsu Corp, Hamamatsu City, Japan). Concerning the kidney function, the quantity of urine produced during the operation was controlled.

The true and the false lumen of the descending aorta were identified. In patients with chronic dissection, a stiff guidewire (Jotec Inc) was inserted after the patient was anesthetized through the right femoral artery into the true lumen under angiographic and transesophageal echo control. In acute cases, the true lumen could be identified by its gross morphologic characteristics, and the guidewire was inserted through the open aortic arch.

Two different techniques of aortic arch replacement were performed:

1 "Complete" arch replacement. The E-vita open stent graft covered with thin textile was inserted into the descending aorta over a stiff guidewire (Fig 2). The landmark for stent graft placement was the origin of left subclavian artery, and deployment was performed 1 cm distally to this landmark. At this time the Dacron prosthesis remained within the stent graft. To perform an anastomosis with the proximal descending aorta, the Dacron graft was pulled slightly out of the stent (1 cm) and sutured to the descending aorta using a running mattress suture reinforced with polytetrafluoroethylene felt strips (Bard PTFE; Impra Inc, Tempe, AZ). The woven crimped vascular Dacron prosthesis was then retracted completely from the implanted stent graft. For reimplantation of the supraaortic branches, an appropriately sized window was transected from the Dacron prosthesis and the arch vessels were anastomosed en bloc (island technique). The left subclavian artery in 1 patient showed severe arteriosclerotic changes and had to be occluded. After air was removed from the arch, the prosthesis was clamped, circulatory arrest was discontinued, and rewarming was initiated. As the next step, the anastomosis with the proximal ascending aorta was performed.

2 "Light" arch replacement. Stent graft insertion and deployment was performed by the technique just described. But in contrast to complete arch replacement, the supraaortic branches were not isolated from the aortic arch. The concavity of the aortic arch was resected by maintaining the convexity. After the stent graft was deployed, the Dacron graft was pulled out and trimmed to a rim of 2 cm. This Dacron rim was reinforced to the proximal descending aorta with a running suture; then, a separate Dacron prosthesis (Vascutek Terumo, Renfrewshire, Scotland, Great Britain) was anastomosed to the concavity of the remaining arch, similar to hemiarch replacement (Fig 3). After the hemiarch anastomosis was accomplished, air was removed. The prosthesis was clamped proximal to the innominate artery, perfusion was reinstated, and the patient was rewarmed. The proximal anastomosis to the ascending aorta was performed subsequently. Owing to the porosity of the uncoated Dacron prosthesis, the time for hemostasis was prolonged and expedited using fibrin glue (Tissucol, Baxter AG, Vienna, Austria) for sealing.

View larger version (147K): [in this window] [in a new window]   Fig 2. Intraoperative photographs (a and b) show placement of the stent graft (Jotec Inc, Hechingen, Germany) into the descending aorta. The Dacron graft is pulled out to perform a hemiarch and ascending aortic repair (c and d).

View larger version (40K): [in this window] [in a new window]   Fig 3. (a) "Light" arch replacement performing an anastomosis with the proximal descending aorta with the Dacron graft (Jotec Inc, Hechingen, Germany) using a running mattress suture and placement of the stent graft to the descending aorta. The brachiocephalic trunk was perfused via the right subclavian artery, and a selective perfusion catheter was installed into the left carotid artery for cerebral protection. The left subclavian artery was blocked by a catheter with an inflatable balloon. (b) Thereafter, a separate prosthesis (Vascutek Terumo, Renfrewshire, Scotland, Great Britain) was anastomosed to the concavity of the remaining arch.

	Results

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
The prosthesis was successfully implanted by the use of an antegrade guidewire in all patients. The total duration in minutes (range) of the cardiopulmonary bypass was 197 ± 29.9 minutes (163 to 244 minutes), the duration of hypothermic circulatory arrest was 60 ± 15.5 minutes (40 to 86 minutes), and aortic cross-clamp time was 88 ± 33.2 minutes (50 to 137 minutes). Deployment of the stented end of the hybrid prosthesis required an average of 10 minutes (range, 8 to 12 minutes). The duration of stay at the intensive care unit was 6.8 days (range, 2 to 21 days), and the hospital stay was 20 days (range, 8 to 35 days).

One patient had a postoperative stroke, and the cranial CT control on postoperative day 2 showed multiple ischemic lesions. The patient had a prolonged ventilation of 6 days. After hospitalization, the patient was referred to a rehabilitation center where his neurologic dysfunctions recovered almost completely. A further patient underwent pericardial drainage through a subxiphoid approach on postoperative day 11 because of a pericardial effusion 2.5 cm in diameter.

The follow-up period was 11 ± 3.8 months (range, 8 to 16 months). CT scans were performed postoperatively within the first 2 weeks and again after 3, 6, and 12 months. The scans showed all stent grafts were in the correct position. Complete thrombus formation in the perigraft space around the stent in the descending aorta was observed in 6 of 7 patients (Fig 4).

View larger version (69K): [in this window] [in a new window]   Fig 4. Computed tomography scans show the stent graft. The prosthesis replaces the ascending aorta and the stent graft is placed within the proximal descending aorta (left). Note complete thrombosis of the perigraft space (right).

Mesenteric and renal arteries were perfused regularly in all patients. One patient received a stent in the renal arteries owing to refractory hypertension postoperatively. During the 1-year follow-up of 3 patients, the false lumen did not increase in extension but was persistently perfused distally to the stent graft due to reentries in the abdominal region.

	Comment

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
The false lumen distal to the aortic graft remained patent in 70% to 100% of patients after repair of acute type A aortic dissection by graft replacement of the ascending aorta with aortic valve repair or replacement [5–8]. Periodic follow-up after repair of acute type A aortic dissection has shown that additional surgery for distal aortic disease is required in 20% to 30% of patients within the first 5 to 7 years due to aneurysmal dilatation of the residual dissected aorta [9, 10]. The traditional staged repair of extensive aortic aneurysm using the elephant trunk technique with cardiopulmonary bypass, hypothermia, and circulatory arrest in the first stage, followed by anterolateral thoracotomy in the second, is associated with longer intensive care unit and hospital stays and a 30-day mortality rate of 9%. The mortality rate during the 5-year follow-up period was 32.1% [11]. The presence of an intimal tear or dilatation in the aortic arch has a negative impact on late survival. Reoperations are indicated in 25% of these patients [12].

This report describes the feasibility of combined surgical and endovascular repair of extensive pathologies of the aorta with specially designed hybrid prostheses. The risk of a persistent perfused false lumen associated with increased dilatation of the descending aorta and compression of the true lumen, followed by impaired distal perfusion, can be minimized by stenting the descending aorta and excluding potential sites of entry. Thrombosis of the false lumen at least to the distal end of the stent graft can be achieved by this combined procedure. Most important, consecutive repair of the descending aorta can be performed without cardiac arrest. This facilitates further operations or interventions in the thoracoabdominal region because of the occlusion of tears and reentries at the descending aorta. Furthermore, the stent graft serves as an ideal fixation site for additional stent grafts in the descending aorta.

Two-stage approaches to complex aortic dissections can be avoided by this one-step procedure. Cumulative risks such as phrenic or recurrent nerve injury as well as pulmonary complications can also be averted by this approach [13].

The procedure is performed through a median sternotomy, which facilitates additional ascending aortic repair and any additional heart surgery that may be required (such as coronary revascularization). The use of a stent graft for treatment of the descending aorta in combination with conventional replacement of the aortic arch combines features of cardiovascular surgery and endovascular approaches. Experience in patients with acute type A aortic dissections has demonstrated the usefulness of this approach [14–16]. In contrast to the conventional elephant trunk operation, this hybrid prosthesis allows the implantation of a self-expandable stent graft into the descending aorta. Thus, the true lumen can be enlarged, possible reentries closed, and thrombosis of the false lumen promoted [17].

We used two techniques for implantation of the hybrid prosthesis. For acute aortic dissections and for patients with hostile anatomy (deep chest or a poorly accessible left subclavian artery), we used the light aortic arch repair in which the concavity of the aortic arch is resected, but supraaortic branches are not isolated. The hybrid prosthesis is implanted into the descending aorta using the 1-cm to 2-cm rim of the Dacron prosthesis for fixation distal to the origin of left subclavian artery. Thereafter, the aortic arch is replaced with a separate Dacron prosthesis, similar to the hemiarch technique. The light aortic arch repair offers several advantages:

1 This approach offers simple access, avoiding complex suture lines at the dorsal region of the aortic arch as in the en bloc or separated graft technique.

2 The period of circulatory arrest can be minimized by the shorter suturing distance and by maintaining the natural convexity.

3 Owing to the excellent visualization of the Teflon felt-supported anastomosis, potential bleeding sites can be identified and easily controlled in the rewarming period.

4 Arch vessels need not be completely exposed, particularly in patients with strong adhesions, for instance during reoperation.

Despite these advantages, light arch repair cannot be recommended in Marfan patients or in those with severe alterations of the aortic wall; for instance, when the intimal tear is located at the greater curvature or in the presence of adherent debris or ulcers [18, 19].

In contrast to the classic elephant trunk described by Borst and colleagues [1], which facilitates consecutive operations at the descending aorta, the hybrid stent graft offers the possibility to exclude arteriosclerotic aneurysms and cover possible reentries in the descending aorta. An entry point located distal to the left subclavian artery can also be closed by the affiliated stent graft, providing a circumferential anastomosis with its proximal vascular graft segment [20, 21]. A prolonged period of circulatory arrest must be taken into account when anchoring the hybrid prosthesis by this internal suture line. The stent graft also serves as an ideal fixation site for additional endovascular treatment of the descending aorta (Fig 5).

View larger version (34K): [in this window] [in a new window]   Fig 5. Consecutive stent grafting of the descending aorta after replacement of the aortic arch and proximal descending aorta by light aortic arch repair using hybrid prosthesis.

In conclusion, the approach of a combined surgical and endovascular technique for the treatment of extensive thoracic aortic disease is feasible and can be performed with good results. Complete thrombosis of the aneurysms or false lumens surrounding the grafts could be achieved in 6 of 7 patients. Late complications such as enlargement of the aortic diameter and rupture may be reduced by this technique. Preliminary results indicate that the new method of hybrid graft implantation with a stented graft should be considered as a less invasive surgical treatment for thoracic aortic aneurysms and dissections. However, further investigations are needed to evaluate the long-term effectiveness of this new combined treatment modality.

	Acknowledgments

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
None of the authors or the host institution is linked in any way to Jotec, Inc. The E-vita open endoluminal stent grafts (Jotec Inc, Hechingen, Germany) used in this study were completely reimbursed by the patients’ insurance companies. The authors were fully responsible for the study design, the methods, the outcome measurements, analysis of data, and the written report.

	References

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 

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