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Ann Thorac Surg 2008;86:1524-1529. doi:10.1016/j.athoracsur.2008.06.075
© 2008 The Society of Thoracic Surgeons
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Original Articles: Adult Cardiac

Supra-aortic Transposition for Combined Vascular and Endovascular Repair of Aortic Arch Pathology

Roman Gottardi, MDa, Martin Funovics, MDb, Nella Eggersa, Alexander Hirner, MSa, Marion Dorfmeister, MDa, Johannes Holfelda, Daniel Zimpfer, MDa, Maria Schoder, MDb, Konstantin Donas, MDa, Ernst Weigang, MDc, Johannes Lammer, MDb, Michael Grimm, MDa, Martin Czerny, MDa,*

a Department of Cardiothoracic Surgery, University of Vienna Medical School, Vienna, Austria
b Department of Interventional Radiology, University of Vienna Medical School, Vienna, Austria
c Department of Cardiothoracic and Vascular Surgery, University Hospital Mainz, Mainz, Germany

Accepted for publication June 13, 2008.

* Address correspondence to Dr Czerny, Waehringer Guertel 18-20, Vienna, A-1090, Austria (Email: martin.czerny{at}meduniwien.ac.at).

Presented at the Poster Session of the Forty-fourth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28–30, 2008.


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 References
 
Background: Supra-aortic transpositions in various extents followed by endovascular stent graft placement are now an established tool in the treatment of various pathologies affecting the aortic arch. Results remain to be determined.

Methods: From 1996 through 2007, 73 patients (median age, 71 years) presented with aortic arch pathology (atherosclerotic aneurysms, n = 42; type B dissections, n = 9; penetrating ulcers, n = 17; traumatic lesions, n = 2; aneurysms based on prior surgery for aortic coarctation, n = 3). Strategy for distal arch disease was subclavian-to-carotid transposition (n = 24) or autologous double-vessel transposition through upper hemisternotomy (n = 36). For entire arch disease, total supra-aortic rerouting with a reversed bifurcated prosthesis was applied (n = 13). Endovascular stent graft placement was performed metachronously.

Results: In-hospital mortality was 6.8% (n = 5). Persistent early type I and III endoleak rate was 9.6%. Persistent late type I and III endoleak rate was 5.5%. Overall actuarial survival was 90%, 86%, and 72% at 1, 3, and 5 years. Mean follow-up is 37 months (range, 1 to 120). Early and late endoleak formation was independently predicted by the number of prostheses (early odds ratio [OR] 0.210, p = 0.0003; late OR 0.216, p = 0.012), whereas logistic EuroSCORE (European System for Cardiac Operative Risk Evaluation) reached borderline significance regarding late endoleaks (OR 2.1, p = 0.095). An earlier year of implantation reached borderline significance predicting survival (OR 1.9, p = 0.062). Furthermore, survival was independently predicted by higher logistic EuroSCORE levels (OR 1.8, p = 0.020). Interestingly, type of arch rerouting did not influence endoleak formation and survival (OR 0.9, p = 0.812).

Conclusions: Results after supra-aortic transpositions in various extents followed by endovascular stent graft placement for the treatment of various pathology affecting the aortic arch are promising. Endoleak formation is directly related to the number of prostheses and may be reduced by longer devices. Each type of arch rerouting, irrespective of extent, has turned out to be effective. Therefore, extended applications of these combined treatment strategies substantially augment the therapeutic options.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 References
 
Conventional surgical repair of aortic arch pathology still is an invasive procedure requiring arch replacement during hypothermic circulatory arrest, thereby carrying a reported mortality between 7% and 17% and a reported rate of gross neurologic injury between 4% and 12%, with a direct correlation between advanced age and adverse outcome [1–3].

Recently, combined vascular and endovascular approaches have emerged as an effective adjunct in the treatment of various pathology of the aortic arch and the proximal descending aorta especially in the high-risk patient not suitable for conventional aortic arch repair owing to cardiovascular or pulmonary comorbidities [4–9].

Standard subclavian-to-carotid artery transposition has evolved from a revascularization procedure for occlusive disease into a landing zone extension procedure for dilatative disease. Transposition of the left common carotid artery as well as the left subclavian artery (double vessel transposition) and finally transposition of all supra-aortic branches (total arch rerouting) are consequently following this approach, extending the potential landing zone for stent graft placement even into the ascending aorta. Nevertheless, results of these combined approaches remain to be determined.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 References
 
Between 1996 and 2007, 73 patients with aortic arch pathology were treated with supra-aortic transposition in various extents followed by endovascular stent graft placement at our department. Patient selection for combined approaches was done on the basis of age and comorbidities. The majority of patients were at high risk for conventional aortic arch surgery owing to cardiovascular, neurologic or pulmonary comorbidities. Patient demographics and clinical risk factors are shown in Table 1. As to our institutional standards, merely 15% of patients would have been suitable candidates for conventional surgery. All patients underwent risk stratification according to EuroSCORE guidelines [10, 11]. Both, additive and logistic values were collected. The Ethics Committee approved the study and waived the need for patient consent.


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  		Table 1 Demographics and Clinical Risk Factors
 
Preoperative Evaluation, Landing Zones, and Surgical Approach
Preoperative evaluation was done by multisclice computed tomography (CT) scans to exclude major occlusive disease of the supra-aortic branches and the aortoiliac axis, for later arterial access for stent graft insertion. Furthermore, these CT scans were used as a tool to predict the required length of the intended proximal landing zone. As a prerequisite for successful stent graft placement, a proximal landing zone of at least 1.5 cm along the lesser curvature of the aortic arch was claimed. Furthermore, after rerouting, an additional CT scan was performed to reconfirm the effective length of the intended landing zone extension.

Subclavian-to-Carotid Artery Transposition
A standard approach through a skin incision parallel to the left clavicula was chosen. The left subclavian artery was devided at its origin at the level of the aortic arch. The vessel was guided dorsal to the left jugular vein, and an end-to-side anastomosis between the left subclavian artery and the left common carotid artery was performed.

Double-Vessel Transposition
The original method has been described in detail previously [7]. Through an upper hemisternotomy approach, all supra-aortic branches are exposed. An end-to-side anastomosis between the left common carotid artery and the brachiocephalic trunk is performed. Afterward, an end-to-side anastomosis between the left subclavian artery and the left common carotid artery finalizes the procedure. Interposition of an 8-mm Dacron graft (C.R. Bard, Haverhill, PA) may be beneficial in certain clinical situations where extensive mobilization of the supra-aortic branches is not sufficient to accomplish tension-free vascular transposition.

Total Arch Rerouting
The original method has also been described in detail previously [9]. Through a full sternotomy approach and opening of the pericardium, an anastomosis between the proximal portion of an inversed bifurcated Dacron prosthesis (Braun Unigraft, Melsungen, Germany) and the ascending aorta is performed. Afterward, an end-to-end anastomosis between the first branch of the prosthesis and the brachiocephalic trunk is performed. The next step is to perform an end-to-end anastomosis between the second branch of the prosthesis and the left subclavian artery. Finally, the left common carotid artery is reinserted into the branch to the left subclavian artery. Temporary atrial and ventricular pacemaker wires are affixed routinely.

Stent Graft Systems Use
Four different commercially available stent graft systems were used. The Talent and, after having been modified, the Valiant endovascular stent graft (Medtronic Inc, Santa Rosa, CA) were used in 23 patients. The Relay stent graft (Bolton Medical, Sunrise, FL) was used in 22 patients. The Excluder stent graft (W. L. Gore & Assoc, Flagstaff, AZ) was used in 27 patients. The Endofit stent graft (LeMaitre Vascular, Burlington, MA) was used in 1 patient. For all systems, the diameter of the stent graft was calculated from the largest diameter of the proximal or distal neck, and an oversizing factor of 10% to 20% was added.

Stent Graft Placement
Stent graft placement was performed during general anesthesia. In the majority of patients, a transfemoral approach was chosen. If the diameter of the external iliac artery was not large enough, the common iliac artery was used for arterial access. Stent graft deployment was routinely performed under hypotonic conditions (60 mm Hg systolic pressure). In patients with an intended landing zone in the cranial ascending aorta, overpacing at 180 beats per minute was used to effectively control deployment of the stent graft. All procedures were performed metachronously, as no hybrid operating room in our institution permitting combined procedures with the same accuracy and safety for the patient currently is available. Median interval between supra-aortic transposition and stent graft placement was 7 days.

Definition of Endoleaks
Endoleaks were defined as to reporting standards [12]. Type I endoleaks were defined as attachment site leaks, type Ia at the proximal attachement site and type Ib at the distal attachement site. Type II endoleaks were defined as branch leaks without attachement site connection. Type III endoleaks were defined as junctional leaks between stent grafts, if more than 1 graft was used. Persistent endoleak rate was defined as the rate of endoleaks persisting after watchful waiting, baloon dilatation, or additional stent graft placement.

Follow-Up Period
Patients were followed up according to a strict follow-up protocol that requires a contrast spiral CT scan and clinical as well as laboratory evaluation at 3, 6, and 12 months after surgery, and then annually thereafter. Magnetic resonance angiography was used alternatively when chronic renal insufficiency or allergy to iodinated contrast were detected. Additional investigations were obtained whenever indicated.

Statistical Analysis
For determining the predictive value of the covariates to forecast early endoleak, late endoleak, or survival respectively, logistic regression analysis with automatic model selection was used, as the primary interest was whether endoleaks occur or not. Event-free survival was tested separately. For modeling binary outcome, the variables age (age of the patient), sex, year of treatment (if surgery was performed before or after 2002), the length of the proximal landing zone in centimeters, the number of prostheses, logistic EuroSCORE (European System for Cardiac Operative Risk Evaluation) levels, and the length of the distal landing zone in centimeters were used. The year 2002 was chosen as cutoff because from 2002 onward, second- and third-generation prostheses were made available. Within a second analysis, the influence of arch rerouting itself and the type of arch rerouting with regard to early and late endoleak formation as well as survival was tested. Therefore, a logistic regression analysis based on the whole dataset, including all patients treated in our department for thoracic aortic disease by stent graft placement, was performed. A significance level of 5% was used; if the p values of certain variables did not reach significance and did not exceed 10%, the terminology "borderline significance" was used. Statistical analysis (generalized linear modelling) was performed using SAS version 9.0 (SAS Institute, Cary, NC).


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 References
 
Surgical Results
No intraoperative death occurred. In 8 patients, additional cardiac or vascular procedures were concomitantly performed (aortic valve replacement n = 1, CABG n = 1, carotid endarterectomy n = 1, aortofemoral bypass n = 1, iliacofemoral bypass n = 2, femoral patch plasty n = 1, strumectomy n = 1). One patient had to undergo revision of both anastomoses owing to local dissection within the first hours after surgery, recovering uneventfully. One patient underwent reexploration for bleeding. Two patients sustained sternal dehiscence with secondary closure.

In-Hospital Mortality
Overall in-hospital mortality was 6.8% (n = 5). Four patients died perioperatively (myocardial infarction n = 2, malignant arrythmia n = 1, transfusion reaction followed by multiorgan failure n =1). Finally, 1 patient died in the waiting period between supra-aortic transpostion and intended stent graft placement due to rupture. Two deaths occurred in patients after double transposition, and 3 deaths occurred in patients after total arch rerouting (Table 2).


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  		Table 2 Results After Stent graft Placement
 
Adverse Neurologic Events
One patient with a heavily calcified ascending aorta undergoing entire arch rerouting due to multiple penetrating atherosclerotic ulcers sustained a temporary neurologic injury, most likely due to embolization during tangential clamping of the ascending aorta, having resolved at the time of discharge.

Length of Landing Zone After Supra-aortic Transpositions
Through subclavian-to-carotid transposition, a median proximal landing zone length of 2.2 cm could be achieved. Double-vessel transposition resulted in a proximal landing zone length of 2.4 cm. Finally, after total arch rerouting, a median landing zone of 3.9 cm was available for stent graft deployment (Table 2).

Early Type I and III Endoleaks and Need for Reinterventions
Early type I and III endoleaks were observed in 18 patients (24.6%). The persistent early endoleak rate was 9.6% (7 patients). The remaining endoleaks were observed because of the inability to perform further endovascular repair, being type I endoleaks not amendable for treatment owing to the lack of landing zone extension. Of these, 2 patients underwent late surgical conversion because of increasing diameter of the aneurysmal sac 45 and 51 months after primary treatment.

Early Type II Endoleaks and Need For Reinterventions
Owing to the extensive rerouting procedures, no type II endoleaks through retrograde perfusion were observed.

Survival
The mean follow-up period was 37 months (range, 1 to 120). Overall actuarial survival was 90%, 86%, and 72% at 1, 3, and 5 years. No difference in survival with regard to the extension of supra-aortic transpositions could be observed.

Late Type I and III Endoleaks and Need for Reinterventions
Late type I and III endoleaks were observed in 10 patients (13.6%). After secondary stent graft placement and baloon dilatation, a remaining persistent late endoleak rate of 5.5% was observed. These patients are closely followed.

Logistic Regression Analysis, Early Endoleak Formation
Early endoleak formation was independently predicted by a higher number of prostheses used (odds ratio [OR] 0.210, p = 0.0003). Interestingly, an earlier year of treatment (OR 1.75, p = 0.845), the underlying aortic disease (OR 0.585, p = 0.507), and the type of arch rerouting (OR 8.084, p = 0.902) did not predict early endoleak formation (Table 3).


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  		Table 3 Logistic Regression Analysis: Early Endoleak Formation
 
Logistic Regression Analysis, Late Endoleak Formation
A higher number of prostheses used (OR 0.216, p = 0.012) turned out to be also the only independent risk factor of late endoleak formation (Table 4).


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  		Table 4 Logistic Regression Analysis: Late Endoleak Formation
 
Logistic Regression Analysis, Survival
Survival was independently predicted by an earlier year of implantation (OR 1.9, p = 0.062) as well as by higher logistic EuroSCORE levels (OR 1.8; p = 0.020). Type of arch rerouting did not influence survival (OR 0.9, p = 0.812; Table 5).


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  		Table 5 Logistic Regression Analysis: Survival
 

   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
References
 
No death related to supra-aortic transposition occurred in this series, thereby emphasizing the safety of these procedures. These results are well in line with the results after stent graft placement without arch involvement [13–16]. Nevertheless, it has to be stated that extensive mobilization of the supra-aortic branches is mandatory to enable tension-free accomplishment of vascular anastomoses [8]. The patient who had to undergo revision of both anastomoses was potentially not sufficiently mobilized, resulting in tension and local dissection. Interposition of an 8-mm Dacron graft may be beneficial in certain clinical situations. Furthermore, reversed-T hemisternotomies may be more prone to dehiscence than full sternotomies, especially the osteosynthesis between the two upper parts of the sternum and the caudal common part may be problematic. Therefore, in selected patients, we do use titanium sternal plates for stabilization. Recently, we have switched to a left sided L-shaped upper hemisternotomy to avoid these challenges.

Although predicted mortality—according to EuroSCORE levels—was by far higher than observed mortality, even these new, minimally invasive approaches are not without risk, reflected by 5 patients dying in hospital.

Four patients died of perioperative cardiovascular events, thereby underlining the substantially high risk profile of this patient population. Notably, 3 patients died after total arch rerouting. We do think that, despite avoiding cardiopulmonary bypass and hypothermic circulatory arrest, total arch rerouting is a more invasive procedure compared with double-vessel transposition and subclavian transposition owing to extended stress burden, resulting from surgical access as well as expenditure of time. Only 1 temporary neurologic injury was observed in this series. We do think that the risk of neurologic injury is in direct relation to the underlying disease. Dilatative arteriopathies are hardly ever related, with severe calcification affecting the ascending aorta as well as the supra-aortic branches, whereas obliterative arteriopathies such as penetrating ulcers frequently are leading to potential embolization during clamping.

Conflicting evidence exists with regard to an ideal length of landing zones [16–19]. Nevertheless, it is generally accepted that a landing zone of 1.5 cm is sufficient. We do proceed one step further and demand at least 2 cm, as data are available showing a direct correlation between the length of the landing zone and persisting or newly developing endoleaks [17]. Furthermore, we aim for an overlap between prostheses of at least 3 cm for the same reason. Interestingly, the length of landing zone after total arch rerouting was substantially longer than after the other types of transposition. This can be explained by the the end-to-side anastomosis between the ascending aorta and the proximal portion of the Dacron prosthesis being routinely performed within the midportion of the ascending aorta because of technical reasons and because the majority of arch pathologies originate at the level of the brachiocephalic trunk and not within the cranial ascending aorta.

Our persistent primary endoleak rate is acceptably low and well in line with other published series [13–16]. In 2 patients, after 45 and after 51 months, late surgical conversion had to be performed owing to progressive dilation of the aneurysmal sac. Both patients underwent stent graft placement in 1997, thereby deriving from the very early series with regard to technical understanding and technology availability, as well as perception of the potential trade-offs of treatment.

Our mean follow-up is 37 months to date, including some patients being observed for as long as 10 years. Survival is also in line with other recently published series. Interestingly, the more proximal extension of the landing zone was required, the higher EuroSCORE levels could be observed. Nevertheless, the type of arch rerouting had no adverse effect on survival, thereby reflecting the safety and efficacy of even these advanced procedures. Logistic regression analysis revealed a higher number of prostheses used as the only independent risk factor of early endoleak formation. With increased device length available up to 25 cm in the meantime, the number of prostheses used can be substantially reduced, thereby improving lateral stability and augmenting overlapping zones.

As a consequence, probability of endoleak formation may be substantially reduced. Interestingly, an earlier year of treatment did not predict early endoleak formation proving our principle of extensive landing zone requirement even in the early days. Likewise, a higher number of prostheses used was the only independent predictor of late endoleak formation. This becomes clear after reflection onto the anatomy of the arch and the tortuosities that may be observed in this region. Interestingly, an earlier year of implantation did not predict late endoleak formation. Furthermore, the length of the proximal landing zone did not predict either early or late endoleak formation, moreover underlining the accuracy of the concept.

Survival was independently predicted by higher logistic EuroSCORE levels and reached borderline significance with regard to earlier year of implantation. This becomes clear as the majority of patients in the early days have been at an advanced age already. Furthermore, the comorbidities associated with higher EuroSCORE levels may be limitating despite aggressive secondary medical preventive therapy. After comparison of supra-aortic transpositions in various extents followed by endovascular stent graft placement with the current literature of conventional repair of isolated arch and distal arch pathology, some striking differences become available [1–3]. Mean age of patients undergoing the new approach is substantially higher. Neurologic injury is neglectable low, and mortality is comparable and in the lower range of the spectrum. Furthermore, as there is a clear correlation between age and death, a substantially higher mortality could be expected if these patients would have undergone any kind of conventional treatment. Without doubt, conventional aortic arch and proximal descending aortic replacement will have their unaffected value in the future in younger patients as well as in patients with connective tissue diseases. However, recovery in patients at high risk for conventional repair is striking, especially as the majority of these patients represent a new cohort that would not have been treated by mere antihypertensive therapy even recently.

Summarizing, results after supra-aortic transpositions in various extents followed by endovascular stent graft placement for the treatment of pathology affecting the aortic arch are promising. Endoleak formation is directly related to the number of prostheses and may be reduced by longer devices. Each type of arch rerouting, irrespective of extent, has turned out to be effective. Therefore, extended applications of these combined treatment strategies substantially augment the therapeutic options.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 

  1. Harrington DK, Walzer AS, Kaukuntla H, et al. Selective antegrade cerebral perfusion attenuates brain metabolic deficit in aortic arch surgery: a prospective randomized trial Circulation 2004;110:II231-II236.[Medline]
  2. Westaby S, Katsumata T, Vaccari G. Arch and descending aortic aneurysms: influence of perfusion technique on neurological outcome Eur J Cardiothorac Surg 1999;15:180-185.[Abstract/Free Full Text]
  3. Bachet J, Guilmet D, Goudot B, et al. Antegrade cerebral perfusion with cold blood: a 13-year experience Ann Thorac Surg 1999;67:1874-1878.[Abstract/Free Full Text]
  4. Criado FJ, Barnatan MF, Rizk Y, Clark NS, Wang C. Technical strategies to expand stentgraft applicability in the aortic arch and proximal descending thoracic aorta J Endovasc Ther 2002;9:II32-II38.[Medline]
  5. Buth J, Penn O, Tielbeek A, Mersman M. Combined approach to stent graft treatment of an aortic arch aneurysm J Endovasc Surg 1998;5:329-332.[Medline]
  6. Dambrin C, Marcheix B, Hollington L, Rousseau H. Surgical treatment of an aortic arch aneurysm without cardio-pulmonary bypass: endovascular stent grafting after extra-anatomic bypass of supra-aortic vessels Eur J Cardiothorac Surg 2005;27:159-161.[Abstract/Free Full Text]
  7. Czerny M, Fleck T, Zimpfer D, et al. Combined repair of an aortic arch aneurysm by sequential transposition of the supraaortic branches and consecutive endovascular stent graft placement J Thorac Cardiovasc Surg 2003;126:916-918.[Free Full Text]
  8. Czerny M, Zimpfer D, Fleck T, et al. Initial results after combined repair of aortic arch aneurysms by sequential transposition of the supra-aortic branches and consecutive endovascular stent graft placement Ann Thorac Surg 2004;78:1256-1260.[Abstract/Free Full Text]
  9. Gottardi R, Seitelberger R, Zimpfer D, et al. An alternative approach in treating an aortic arch aneurysm with an anatomic variant by supraaortic reconstruction and stent graft placement J Vasc Surg 2005;42:357-360.[Medline]
  10. Nashef SAM, Roques F, Michel P, Gauducheau E, Lemeshow S, Salomon R. European System for Cardiac Operative Risk Evaluation (EuroSCORE) Eur J Cardiothorac Surg 1999;16:9-13.[Abstract/Free Full Text]
  11. Michel P, Roques F, Nashef SAM. Logistic or additive EuroSCORE for high-risk patients Eur J Cardiothorac Surg 2003;23:684-687.[Abstract/Free Full Text]
  12. Chaikof EL, Blankensteijn JD, Harris PL, et al. Reporting standards for endovascular aortic aneurysm repair J Vasc Surg 2002;35:1048-1060.[Medline]
  13. Criado F, Abul-Khoudoud OR, Domer GS, et al. Endovascular repair of the thoracic aorta: lessons learned Ann Thorac Surg 2005;80:857-863.[Abstract/Free Full Text]
  14. Fattori R, Nienaber CA, Rousseau H, et al. Results of endovascular repair of the thoracic aorta with the Talent thoracic stent graft: the Talent Thoracic Retrospective Registry J Thorac Cardiovasc Surg 2006;132:332-339.[Abstract/Free Full Text]
  15. 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 endoprosthesis J Vasc Surg 2005;41:1-9.[Medline]
  16. Wheatley III GH, Gurbuz AT, Rodriguez-Lopez JA, et al. Midterm outcome in 158 consecutive Gore TAG thoracic endoprostheses: single center experience Ann Thorac Surg 2006;81:1570-1577.[Abstract/Free Full Text]
  17. Czerny M, Grimm M, Zimpfer D, et al. Results after endovascular stent graft placement in atherosclerotic aneurysms involving the descending aorta Ann Thorac Surg 2007;83:450-455.[Abstract/Free Full Text]
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  19. Antona C, Vanelli P, Petulla M, et al. Hybrid technique for total arch repair: aortic neck reshaping for endovascular-graft fixation Ann Thorac Surg 2007;83:1158-1161.[Abstract/Free Full Text]



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