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Ann Thorac Surg 2008;86:1989-1991. doi:10.1016/j.athoracsur.2008.04.099
© 2008 The Society of Thoracic Surgeons
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Case Reports

Hybrid Procedure for Proximal Arch and Descending Aortic Aneurysms

Victor X. Mosquera, MDa,*, Vicente Campos, MDa, Milagros Marini, MD, PhDb, Jose V. Valle, MDa, Ignacio Cao, MDb, Daniel Gulias, MDb, Alberto Juffé, MD, PhDa

a Department of Cardiothoracic Surgery, Juan Canalejo Hospital, A Coruña, Spain
b Department of Interventional Radiology, Juan Canalejo Hospital, A Coruña, Spain

Accepted for publication April 25, 2008.

* Address correspondence to Dr Mosquera, Cardiac Surgery Department, Hospital Juan Canalejo, As Xubias 84, A Coruña, CP 15006, Spain (Email: vxmr{at}yahoo.es).


   Abstract
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 Abstract
Introduction
 Comment
 References
 
This report describes the feasibility of combined surgical and endovascular repair of extensive pathologies of the aorta with a specially hybrid procedure. An ascending aorta and proximal aortic arch aneurysm, involving the origin of the innominate artery, and a descending thoracic aorta aneurysm were simultaneously repaired in a 65-year-old man. The ascending aorta, proximal arch, and the origin of the innominate artery were replaced by Dacron grafts (InterVascular, Datascope, La Ciotat, France) under circulatory arrest and deep hypothermia. After weaning from extracorporeal circulation, the thoracoabdominal aneurysm was excluded with two endografts deployed in an antegrade fashion through a side branch of the ascending aorta graft.


   Introduction
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 Abstract
 Introduction
Comment
 References
 
Complex aortic aneurysms pose a challenging surgical problem. Several techniques have been proposed to cope with complex aneurysms that simultaneously affect the ascending and descending aortas. However, until recently, open surgical repair was the only effective treatment with substantial perioperative risk and mortality [1]. Endovascular stent-graft placement has developed as a safe and effective treatment modality in various diseases of the descending aorta [2–4].

In an effort to reduce this risk and therefore improve long-term outcome, we adopted a more aggressive combined surgical approach with resection of the ascending aorta and hemi-arch and endovascular stent deployment within the proximal segment of the descending aorta.

A 65-year-old man was referred to our institution with the diagnosis of an ascending aorta and proximal aortic arch aneurysm, involving the origin of the innominate artery, and a simultaneous thoracoabdominal aneurysm. The patient also presented severe peripheral artery disease.

A gadolinium-enhanced cardiovascular magnetic resonance (CMR) demonstrated a dilatation of the ascending aorta (48 mm of diameter) and a proximal aortic arch aneurysm (57 mm of diameter) with a saccular aneurysm and intraluminal thrombus at the level of the innominate artery origin (Fig 1). The aortic arch between the innominate artery origin and the left subclavian artery origin was preserved (31 mm of diameter). The CMR also showed a thoracoabdominal aortic aneurysm extending from the left subclavian artery origin to the esophageal hiatus (Crawford type I) with a maximum diameter of 67 mm and intraluminal thrombus. The aorta beyond the esophageal hiatus was normal (diameter, 33 mm) (Fig 1).


Figure 1
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  		Fig 1. Gadolinium-enhanced cardiovascular magnetic resonance (CMR) image. The three-dimensional volume rendering CMR demonstrates the distance and relationships among the ascending aorta aneurysm (white arrow), the aneurysm of the origin of the innominate artery (white dashed arrow), descending aorta aneurysm (white dotted arrow), and the preserved middle and distal aortic arch (black asterisk).

 
According to the patient's high surgical risk and the possibility of preserving the native middle distal aortic arch, a combined open and endovascular surgery was selected.

The ascending aorta and proximal aortic arch aneurysms were dissected free. A side-branched Dacron graft (InterGard Woven HemaBridge; InterVascular, Datascope, La Ciotat, France) (diameter, 30 x 10 mm and length, 35 x 40 mm) was used to replace the ascending aorta and proximal aortic arch. An extra side branch was added by anastomosing another Dacron graft (diameter, 10 mm; InterVascular, Datascope) to the anterior surface of the 30-mm diameter graft.

The right axillary artery was used for arterial cannulation during the cooling phase. Afterward, it was used to maintain antegrade cerebral perfusion during the hypothermic circulatory arrest period.

Under circulatory arrest and deep hypothermia, the ascending aorta from the sinotubular junction to the proximal aortic arch was resected and the innominate artery was transected. The 30-mm diameter Dacron graft was used to reconstruct the ascending aorta and proximal aortic arch, whereas the extra 10-mm diameter side-branch graft was used to re-implant the innominate artery.

Once the ascending aorta and proximal arch replacement were accomplished, cardiopulmonary bypass was resumed with a usual aortic cannula placed through the 10-mm Dacron side branch.

The deep hypothermic circulatory arrest time was 20 minutes, and the total cardiopulmonary bypass time was 145 minutes.

After weaning from extracorporeal circulation and on the beating heart, the original 10-mm diameter side-branch graft was used to deploy a Valiant Thoracic Endograft (Medtronic, Santa Rosa, CA), 44 mm in diameter and 150 mm in length, distal to the left subclavian artery origin. A second Valiant endograft (42 mm in diameter and 100 mm in length; Medtronic) was overlapped to the first one to cover the full length of the thoracoabdominal aneurysm from the origin of the left subclavian artery to the level of the esophageal hiatus.

There were neither neurologic nor vascular complications. The patient stayed 5 days in the intensive care unit of the hospital and was later discharged. A multi-slide contrast-enhanced computed tomographic scan was performed 3 weeks later showing a successful exclusion of the thoracoabdominal aneurysm without evidence of any leak in the thoracic graft (Fig 2).


Figure 2
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  		Fig 2. Multi-slide, contrast-enhanced computed tomographic scan. (a) Sagittal reconstruction of the ascending aorta, aortic arch, and descending aorta showing the Dacron graft (InterGard Woven HemaBridge; InterVascular, Datascope, La Ciotat, France) replacing the ascending aorta and proximal arch (white arrow). There is no contrast leak to the aneurysm whose lumen is thrombosing (white dashed arrow). Notice the presence of a mild left pleural effusion (dotted white arrow). (b) Three-dimensional reconstruction of the aortic arch and descending aorta. The white arrows mark the origin of the innominate artery (solid arrow) and the left subclavian artery (dashed arrow).

 
Three months after discharge, the patient was reviewed at the outpatient clinic and remained asymptomatic.


   Comment
Top
 Abstract
 Introduction
 Comment
References
 
This report describes the feasibility of combined surgical and endovascular repair of extensive pathologies of the aorta with a specially hybrid procedure.

Aneurysms of the ascending and descending thoracic aorta are typically managed with two operations. However, staged procedures for extensive aneurysmal disease of the thoracic aorta are associated with a substantial cumulative mortality for the two procedures and death in the interval between, which is often from aortic rupture [5]. The first stage involves replacement of the ascending aorta with a mortality and stroke risk of 8% [6]. The second stage involves replacement of the descending aorta with a mortality of 5% and a paraplegia risk of 5% to 10% [6].

This hybrid procedure offers the possibility to exclude arteriosclerotic descending aorta aneurysms after conventional ascending aorta aneurysm repair with a substantial decrease in both the extracorporeal and circulatory arrest times.

One of the major advantages of this technique lies in the fact that extracorporeal circulation and deep hypothermic circulatory arrest with their inherent risks are shortened. Insertion of the stent graft to cover descending aorta aneurysm is performed through the side-branch graft after reconstruction of the ascending aorta and proximal arch. Therefore, this procedure also avoids navigating the endograft through peripheral arteries, which usually presents severe tortuosity and atherosclerotic disease.

In our opinion, this considerably reduces the risk of both cerebral and peripheral embolism during the endovascular steps.

We believe that combined approaches for arch aneurysms will extend the indications in this delicate anatomic region. Actually a variety of adjunctive techniques to enable stent-graft placement in patients with arch aneurysms is now available [7, 8]. Therefore, an extended application of these techniques will enable safe and effective treatment of this highly selected subgroup of patients with aortic aneurysms by avoiding conventional arch aneurysm repair in deep hypothermia and circulatory arrest.


   References
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 Abstract
 Introduction
 Comment
 References
 

  1. Kazui T, Washiyama N, Muhammad BA, Terada H, Yamashita K, Takinami M. Improved results of atherosclerotic arch aneurysm operations with a refined technique J Thorac Cardiovasc Surg 2001;121:491-499.[Abstract/Free Full Text]
  2. Dake MD, Kato N, Mitchell RS, et al. Endovascular stent-graft placement for the treatment of acute aortic dissection N Engl J Med 1999;340:1546-1552.[Medline]
  3. Nienaber CA, Fattori R, Lund G, et al. Nonsurgical reconstruction of thoracic aortic dissection by stent-graft placement N Engl J Med 1999;340:1539-1545.[Medline]
  4. Dake MD, Miller DC, Semba CP, Mitchell RS, Walker PJ, Liddell RP. Transluminal placement of endovascular stent-grafts for the treatment of descending thoracic aortic aneurysms N Engl J Med 1994;331:1729-1734Dec 29.[Medline]
  5. Kouchoukos NT, Mauney MC, Masetti P, Castner CF. Optimization of aortic arch replacement with a one-stage approach Ann Thorac Surg 2007;83:S811-S814discussion S24-31.[Abstract/Free Full Text]
  6. Beaver TM, Martin TD. Single-stage transmediastinal replacement of the ascending, arch, and descending thoracic aorta Ann Thorac Surg 2001;72:1232-1238.[Abstract/Free Full Text]
  7. 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]
  8. Carrel TP, Do DD, Triller J, Schmidli J. A less invasive approach to completely repair the aortic arch Ann Thorac Surg 2005;80:1475-1478.[Abstract/Free Full Text]




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