Ann Thorac Surg 2008;85:666-668. doi:10.1016/j.athoracsur.2007.04.015
© 2008 The Society of Thoracic Surgeons
How To Do It
A Novel Technique of Deployment of a Thoracic Endograft in the Hybrid Treatment of a Patient With Thoracoabdominal Aneurysm
Jacques Kpodonu, MD*,
Hani Shennib, MD,
Grayson H. Wheatley, III, MD,
Venkatesh G. Ramaiah, MD,
Edward B. Diethrich, MD
Department of Cardiovascular and Endovascular Surgery, Arizona Heart Hospital and Arizona Heart Institute, Phoenix, Arizona
Accepted for publication April 2, 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).
| Dr Wheatley discloses a financial relationship with W. L. Gore & Associates.
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Abstract
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Repair of thoracoabdominal aneurysm is associated with high morbidity and mortality. We describe a hybrid approach to repair a Crawford type III thoracoabdominal aneurysm with antegrade deployment of the endoluminal graft through a side limb of the bifurcated inflow conduit. The advantage of this technique includes avoidance of thoracotomy, left heat bypass, hypothermia, and aortic cross clamping.
Endovascular techniques have been successfully used to treat a variety of lesions in the thoracic aorta, including aneurysms, dissecting aneurysms, penetrating ulcers, aortobronchial fistulas, acute transections, and complications of previous aortic repairs [1, 2]. Compared with open surgery, results of endoluminal grafting have been favorable with reduced blood loss, fewer spinal cord complications, shorter operating times and hospital stays, and more rapid recovery.
Despite the advantages of endovascular interventions, the complexity of certain thoracic aortic pathologies frequently demands that techniques be modified to include more than one type of approach. Hybrid procedures that combine open and endovascular procedures are often necessary to correct complex aortic pathologies [3, 4]. We describe a case of total abdominal debranching with deployment of a thoracic endoluminal graft through a side limb of the inflow conduit to exclude a type III thoracoabdominal aneurysm.
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Technique
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A 71-year-old woman with complaints of back pain was found to have a type III thoracoabdominal aneurysm measuring 5.3 cm x 6.1 cm, extending from the mid-descending thoracic aorta up to the level of the renal arteries on a routine computed tomographic scan of the chest and abdomen (Figs 1A,
1B). Past medical history was notable for coronary artery disease and chronic obstructive lung disease. A hybrid approach consisting of total abdominal debranching with exclusion of the aneurysm with an endoluminal graft was offered.
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Fig 1. (A, B) Computed tomographic scans demonstrate a thoracoabdominal aneurysm with thrombus in the sac.
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A midline laparotomy incision was performed. Surgical exposure of the right, left renal, celiac and superior mesenteric arteries were performed. Heparin (5,000 units) was given and a partial clamp was placed on the distal aorta. A 6-mm Hemashield Dacron (Boston Scientific Corp, Natick, MA) limb was sewn to a bifurcated 12-mm Hemashield Dacron graft as an end-to-side anastomosis (Fig 2A). The 12-mm bifurcated Hemashield Dacron graft was anastomosed to the distal abdominal aorta with a 4-0 Prolene suture (Ethicon, Somerville, NJ) to serve as the inflow blood source with the side limb of the bifurcated graft to be used for antegrade delivery of the endoluminal graft. The attached 6-mm Dacron limb was then sewn as an end-to-end anastomosis to the celiac artery after ligating the ostium (Fig 2B). Subsequently, two 6-mm and an 8-mm Dacron graft were anastomosed end-to-side to the 12-mm inflow limb and were anastomosed end-to-end to the celiac, right renal arteries (6-mm graft) and the left renal artery (8-mm graft) sequentially as end-to-end anastomosis after ligating each of these vessels at their ostium. A radio opaque marker was then placed around the inflow portion of the 12-mm Hemashield graft for deployment of thoracic endoluminal graft under fluoroscopic guidance. Due to the small size, tortuosity and heavy calcification of the iliac arteries at the end of the 12-mm inflow graft was used as a conduit for deployment of the endoluminal graft under fluoroscopic guidance. A 9-French sheath was secured to the side limb of the 12-mm bifurcated graft conduits and a 260-cm extra stiff guidewire was passed through the conduit into the thoracic aorta. The conduit was clamped, and the GoreTAG delivery sheath (W. L. Gore & Associates, Flagstaff, AZ) was substituted for the 9-French sheath (Fig 2C). A marker was placed on the conduit, which assured that the stent-graft was deployed just beyond the limb origins of the graft. The endograft was positioned just proximal to the marker as the sheath was withdrawn into the conduit. The endograft was deployed after completion angiography, the delivery sheath was removed, and the conduit was transected and oversewn (Fig 2D). Heparinization was reversed and the abdominal incision was closed. The patient had an unremarkable hospital stay with a pre-discharge computed tomographic scan of the abdomen showing no endoleak (Fig 3).
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Fig 2. (A) A 12-mm bifurcated Dacron graft (Boston Scientific Corp, Natick, MA) with an attached 6-mm limb sewn to the abdominal aorta, (B) with the 6-mm limb anastomosed to the celiac artery, (C) with antegrade deployment of the thoracic endograft through the 12-mm bifurcated side limb of the inflow conduit, and (D) with deployment of endograft and transection and oversewing of the 12-mm Dacron graft side limb.
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Fig 3. (A, B) Computed tomographic scans with patent flow to the transposed visceral and renal arteries with no endoleak.
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Comment
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Heavy calcification, small diameter, and tortuous iliac arteries make the normal retrograde femoral approach for deployment of thoracic endograft hazardous. The use of temporary or permanent conduits to deliver the prosthesis can overcome these obstacles in the majority of patients. Direct deployment of an endoluminal graft through a side arm of the inflow can technically avoid the numerous access problems that are sometimes encountered during a retrograde femoral approach. The inflow conduit is marked with a radio opaque marker to serve as a guide to prevent deployment of the endoluminal graft across the inflow which would result in ischemia to the abdominal viscera and kidneys. Abdominal debranching of the viscerals and renal arteries is still a formidable operation; however, this hybrid technique provides a unique opportunity for high-risk patients with thoracoabdominal aneurysms who would otherwise not be considered endovascular candidates. The avoidance of a thoracotomy incision, possible left heart bypass, and aortic cross clamping may contribute to the decrease in morbidity and mortality of the operation. We have performed a hybrid debranching procedure on 14 patients with Crawford type I (n = 6), type IV (n = 6), and type III (n = 2) thoracoabdominal aneurysms with a survival rate of 93%. There was no incidence of paraplegia with 2 patients suffering from worsening renal failure, 2 patients with limb ischemia, and 1 patient with visceral ischemia who died within 30 days due to complications from the procedure. This technique can be applied to the treatment of arch aneurysms with translocation of the great vessels and delivery of the endoluminal graft by antegrade or retrograde delivery [5]. Contraindications to this technique would include cases in which there is no source of inflow either due to diseases of the distal aorta or iliac vessels. Possible pitfalls of this procedure include the need for regular surveillance to detect endoleaks and the lack of no long-term data to validate this technique as the standard of care.
In conclusion, total visceral and renal debranching with deployment of endoluminal graft avoids the morbidity associated with cross clamping the aorta, left heat bypass, and thoracotomy. Antegrade deployment of an endoluminal graft through a side arm of a bifurcated graft is a novel technique to deploy an endoluminal graft in cases in which the iliac arteries are small, heavily calcified, and tortuous.
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References
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- Makaroun MS, Dillavou ED, Kee ST, et al. Endovascular treatment of thoracic aortic aneurysms: results of the phase II multicenter trial of the GORE TAG thoracic prosthesis J Vasc Surg 2005;41:1-9.[Medline]
- Wheatley GH, Gurbuz AT, Rodriguez-Lopez JA, et al. Midterm outcome in 158 consecutive Gore TAG thoracic endoprostheses: a single-center experience Ann Thorac Surg 2006;81:1570-1577.[Abstract/Free Full Text]
- Fulton JJ, Farber MA, Martson WA, et al. Endovascular stent–graft repair of pararenal and type IV thoracoabdominal aneurysms with visceral reconstruction J Vasc Surg 2005;41:191-198.[Medline]
- Chiesa R, Melissano G, Civilini E, et al. Two stage combined endovascular and surgical approach for recurrent thoracoabdominal aortic aneurysm J Endovasc Ther 2004;11:330-333.[Medline]
- Bergeron P, Coulon P, De Chaumaray T, et al. Great vessels transposition and aortic archexclusion J Cardiovasc Surg (Torino) 2005;46:141-147.[Medline]
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Abstract
Introduction
