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How To Do It

Closure of Type I Endoleaks and Landing Zone Preparation of the Thoracic Aorta

^a Division of Thoracic and Cardiovascular Surgery, University of Florida, College of Medicine, Gainesville, Florida
^b Division of Vascular Surgery and Endovascular Therapy, University of Florida, College of Medicine, Gainesville, Florida

Accepted for publication September 18, 2007.

^_* Address correspondence to Dr Hess, Division of Thoracic and Cardiovascular Surgery, University of Florida, College of Medicine, PO Box 100286, 1600 SW Archer Rd, Gainesville, FL 32610 (Email: hesspj{at}surgery.ufl.edu).

	Abstract

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Type I endoleaks occasionally persist after endovascular repair of thoracic aneurysms. A technique for repair is described using dimensions obtained from preoperative imaging, in which the aorta is banded at the endograft attachment zone. Aortic remodeling and aortic dimensional stability are the mainstays of the approach. Measured banding has also proved to be useful for the preparation of a landing zone prior to endograft placement during hybrid procedures.

	Introduction

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Type I endoleaks are usually identified during computed tomographic angiography after thoracic endovascular aortic repair (TEVAR) (Fig 1). Endoleak occlusion can often be accomplished by wrapping and cinching a Dacron tube graft (DuPont, Wilmington, DE) around the aorta. An approach to this repair, using periaortic prosthetic grafts sequentially tightened around the landing zone, is locally known as the Florida Cinch.

View larger version (119K): [in this window] [in a new window]   Fig 1. Computed tomographic angiography demonstrates a type I endoleak in the distal descending thoracic aorta.

	Technique

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The right lateral decubitus position is used. Single lung ventilation using a double lumen endotracheal tube is helpful, but not required. Blood pressure is monitored in a radial and femoral artery looking specifically for inadvertent aortic narrowing. The repair is approached through a lateral incision. The fourth intercostal space is used for leaks near the proximal end of an endograft and if isolation of arch vessels is necessary. Distal type I endoleaks at the aortic hiatus are approached through the seventh or eighth intercostal spaces. Using a single posterolateral skin incision, concurrent entry through the fourth and eighth intercostal spaces provides access to both ends of the descending thoracic aorta. Intercostal arteries are ligated and divided as needed for exposure, and intercostals causing type II endoleaks are clip occluded.

The aorta is encircled near the origin of the leak. Dissection is limited to the level of the landing zone. Rough manipulation of the aorta is avoided so a clot from around the endograft is not expressed into the aorta. The predicted circumference at the level of the endoleak is closely estimated using the diameter of the indwelling stent plus the thickness of the aortic wall:

Using this predicted circumference, a flattened Dacron tube graft (16 to 26 mm internal diameter; DuPont) is measured and marked in its mid-length portion and passed around the aorta at the endograft landing zone. The tube graft is flattened when applied; this two-layer wrap is not likely to stretch significantly in an extravascular location. Therefore, the measurements are not adjusted for possible graft stretching or dilation. The distal ends of the band are used for handling and are purposely outside the measured length. Arch vessels and important intercostals may limit the length of accessible aorta, but for closing type I endoleaks the width of the band need only cover the attachment zone.

The tube graft is looped loosely around the aorta and initially adjusted to a length of 2 to 3 cm longer than the predicted circumference needed to seal the endograft. The ends of the flattened graft are held side-to-side using a Kelly-type clamp placed alongside the aorta. The graft circumference is decreased by placing a second Kelly clamp directly behind the first, and so on sequentially. The result of sequentially decreasing the aortic circumference, or cinching, is measured using an epiaortic color-flow duplex ultrasound probe. Artifact from the metal skeleton and fabric of the endograft often interferes with the examination. Simple direct palpation to assess the loss of the endoleak thrill and reduced endotension in the aneurysm sac or false lumen have actually proved more helpful in confirming endoleak closure than any Doppler or echocardiographic techniques. Cinching the band significantly more than the circumference calculated from preoperative imaging will distort the endograft and may disrupt the attachment zone.

The Dacron band is applied with equal tension circumferentially and areas of the band that are not initially snug may eventually slacken and allow the endoleak to reopen. Excessive constriction in one region of the circumference may cause the aortic wall to crimp, disrupting the seal between the endograft and aorta. Thin-walled dissections and some highly attenuated atherosclerotic aneurysms are prone to crimp or fold when banded. Crimping is largely avoided by gently teasing both ends of the graft band around the aortic circumference. Separation of an endograft from the landing zone has not occurred, but it is apparent that the aorta and endograft can be distorted by moderate constriction. The graft, when tightened sufficiently to stop the endoleak, is secured by placing pledgetted horizontal mattress sutures directly behind the last Kelly clamp placed, and straight through the fabric of both limbs of the graft band (Fig 2). After side-to-side fixation to secure the circumference length and band tension, the lateral edges of the graft are sutured to aortic adventitia to prevent band migration. Postoperative computed tomographic angiography confirms endoleak closure.

View larger version (107K): [in this window] [in a new window]   Fig 2. Operative appearance of the completed band wrap at the distal landing zone of the descending thoracic aorta.

Wider grafts are preferable for landing zone preparation (24 to 34 mm internal diameter) to create a stable aortic length of at least 3.5 to 5 cm. If the band width is limited by contiguous branch vessels, strategic keyholes and vessel transposition are useful adjuncts.

This technique has been used to occlude type I endoleaks successfully in 5 consecutive patients after TEVAR. Average follow-up is 9 months after cinch-band placement (range, 6 to 18 months). Aneurysm cause was atherosclerotic in 2 patients and dissection in 3 (1 type I and 2 type III). Patient ages were 52 to 72 years (3 males; 2 females). Time after TEVAR to endoleak repair was immediate, 1 day, and 1 month, 2 months, and 12 months for each of the 5 patients. Two patients presented to the cardiovascular surgery service with significant complications of paraplegia (1 patient) and acute kidney injury (1 patient). Symptoms of occipital ischemia from a new left subclavian steal after TEVAR developed in 1 patient, which required carotid-subclavian bypass. Complications from the banding procedure were limited to left vocal cord paralysis in 1 patient.

	Comment

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Thoracic surgeons have wrapped Dacron grafts around leaking handsewn anastamoses for years. Now, using sophisticated preoperative imaging, it is possible to predict the length and width of the graft most appropriate for this purpose. Unlike a simple leaking anastamosis, a deployed endograft presents some unique features. It supports the aortic wall and provides a helpful semi-rigid scaffold against which to compress the aorta. However, it can be distorted and displaced, and excessive compression may produce landing zone separation or aortic obstruction. Our working principle is to create dimensional stability in the landing zone and avoid excessive constriction.

The use of aortic banding for landing zone preparation during the pre-TEVAR performance of arch vessel transposition has been described [1], and we have used this technique. The modification in the present report presents a more precise method of measuring and applying Dacron grafts for the occlusion of type I endoleaks and for preparation of an aortic landing zone prior to TEVAR. A thoracoscopic approach for band placement may be possible, but direct palpation of the aorta at the endoleak site for confirmation of leak closure favors thoracotomy. Ultrasound examination has not been a reliable alternative to palpation using either the epiaortic or transesophageal approach.

Hybrid open and endovascular repair of thoracic aneurysms continues to evolve. Arch vessel transposition, aortic banding, and endograft placement for treatment of thoracic aneurysms has been reported [2]. The addition of landing zone remodeling techniques using measurements obtained from preoperative imaging may encourage routine arch vessel transposition, landing zone preparation, and TEVAR during the same anesthetic for selected arch aneurysms.

	References

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1. Bergeron P, Mangialardi N, Costa P, et al. Great vessel management for endovascular exclusion of aortic arch aneurysms and dissections Eur J Vasc Endovasc Surg 2006;32:38-45.[Medline]
2. Melissano G, Civilini E, Bertoglio L, et al. Results of endografting of the aortic arch in different landing zones Eur J Vasc Endovasc Surg 2007;33:561-566.[Medline]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Peter Mikhail Charles T. Klodell Thomas M. Beaver Anthony Lee Curtis G. Tribble Tomas D. Martin Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Mikhail, P. Articles by Martin, T. D. Search for Related Content PubMed PubMed Citation Articles by Mikhail, P. Articles by Martin, T. D. Related Collections Great vessels