ATS
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

Ann Thorac Surg 2009;87:603-607. doi:10.1016/j.athoracsur.2008.08.036
© 2009 The Society of Thoracic Surgeons
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Ernst Weigang
Jack Parker
Martin Czerny
Ali A. Peivandi
Friedhelm Beyersdorf
Michael P. Siegenthaler
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Weigang, E.
Right arrow Articles by Siegenthaler, M. P.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Weigang, E.
Right arrow Articles by Siegenthaler, M. P.
Related Collections
Right arrow Great vessels
Right arrowRelated Article

New Technology

Endovascular Aortic Arch Repair After Aortic Arch De-branching

Ernst Weigang, MDa,*,*, Jack Parker, MDa,*, Martin Czerny, MDb, Ali A. Peivandi, MDa, Bernhard Dorweiler, MDa, Friedhelm Beyersdorf, MDc, Michael P. Siegenthaler, MDd

a Department of Cardiothoracic and Vascular Surgery, University Hospital Mainz, Mainz, Germany
b Department of Cardiothoracic Surgery, University Hospital Vienna, Vienna, Austria
c Department of Cardiovascular Surgery, University Cardiovascular Center Freiburg–Bad Krozingen, Freiburg, Germany
d Division Cardiac Surgery, The Heart, Lung, and Esophageal Surgery Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania

Accepted for publication August 18, 2008.

* Address correspondence to Dr Weigang, Department of Cardiothoracic and Vascular Surgery, University Hospital Mainz, Langenbeckstrasse 1, Mainz, 55131, Germany (Email: weigang{at}uni-mainz.de).


   Abstract
Top
 Abstract
Technology
 Technique
 Clinical Experience
 Comment
 Disclosures and Freedom of...
 Footnotes
 References
 
Purpose: Conventional surgical therapy of aortic arch aneurysms consists of aortic arch replacement requiring cardiopulmonary bypass and deep hypothermic circulatory arrest. This method is associated with significant morbidity and mortality, mainly due to neurologic complications and the sequelae of deep hypothermic circulatory arrest. Thus, it makes sense to work on developing less invasive surgical techniques.

Description: Surgical aortic arch de-branching is required before the supra-aortic vessels can be safely covered by an endovascular stent graft. We describe how the supra-aortic vessels can best be revascularized, followed by complete coverage of the aortic arch with endovascular stent grafts.

Evaluation: We hereby present our case selection criteria, preoperative work-up, and surgical approach for aortic arch de-branching with supra-aortic revascularization, followed by complete coverage of the aortic arch by endovascular stent grafting. This technique's safeguards and pitfalls are described for a cohort of 26 patients.

Conclusions: Endovascular aortic arch repair after aortic arch de-branching has the potential to lower the morbidity and mortality rates in patients with aortic arch diseases.


   Technology
Top
 Abstract
 Technology
Technique
 Clinical Experience
 Comment
 Disclosures and Freedom of...
 Footnotes
 References
 
Endovascular aortic arch repair (EVAAR) is less invasive compared with open surgical aortic arch repair in treating aortic arch disease; this correlates with low morbidity and mortality rates, even in high-risk patients [1]. Aortic arch pathologies, such as aneurysms or dissections, often involve the origin of the supra-aortic branches. In that case, it may be necessary to cover the origin of the supra-aortic vessels using endovascular stent grafts (ESGs) to extend the proximal landing zone. Without revascularization of the supra-aortic branches, a range of neurologic and vascular complications may ensue [2, 3]. Surgical aortic arch de-branching is therefore indicated before covering the brachiocephalic trunk (BT) and left common carotid artery (LCCA) by ESGs. As we demonstrated in a previous investigation, the left subclavian artery (LSA) does not need to be revascularized in the absence of supra-aortic pathology [4].

We now describe how the BT and LCCA can best be revascularized, followed by complete coverage of the aortic arch with ESGs.


   Technique
Top
 Abstract
 Technology
 Technique
Clinical Experience
 Comment
 Disclosures and Freedom of...
 Footnotes
 References
 
Patients
We performed EVAAR after aortic arch de-branching in 26 patients. We chose the endovascular approach over conventional aortic arch replacement with cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest in selected patients considered at high-risk due to multiple comorbidities and advanced age (Fig 1). Aortic arch pathology consisted of an aneurysm in 15 cases, and 6 patients presented a previous aortic dissection with development of an aortic arch aneurysm. A penetrating ulcer in the aortic arch was the underlying pathology in five cases. The ethics committees approved the study and waived the need for patient consent.


Figure 1
View larger version (68K):
[in this window]
[in a new window]

  		Fig 1. Preoperative computed tomographic angiography of a patient with aortic arch aneurysm.

 
Arch Vessel Revascularization
Surgery was initiated with an upper right, L-shaped, hemi-sternotomy to the third or fourth intercostal space. After exposing the ascending aorta, the supra-aortic vessels were dissected and the innominate vein was encircled. Then the ascending aorta was tangentially clamped after systemic heparinization, and a longitudinal arteriotomy was performed. An end-to-side anastomosis between the proximal portion of a bifurcated polyester prosthesis (14 x 7 mm or 16 x 8 mm, Gelweave; Vascutek, Renfrewshire, Scotland) and the ascending aorta was done with a 4-0 Prolene running suture (Ethicon Inc, Somerville, NJ). The cross clamp was then released and the air was removed from the graft (Fig 2). If there was a shortage of room in which to sew the main body of the bifurcated graft to the ascending aorta, a 10-mm polyester graft could be fashioned to the ascending aorta, reducing the space required for the anastomosis. Subsequently, an end-to-side 8-mm polyester graft was sewn onto the 10-mm polyester graft for anastomosis to the LCCA (Fig 3). The supra-aortic vessels were then exposed. First the BT was clamped tangentially, followed by longitudinal arteriotomy, and one branch of the bifurcated graft (or T-graft) was anastomosed end-to-side to the BT. Then the LCCA was clamped tangentially, followed by longitudinal arteriotomy, and an end-to-side anastomosis was done to the LCCA with the other branch of the bifurcated graft (or T-graft) (Figs 2 and 3). Each anastomosis was followed by proximal ligature of the vessel to prevent a type II endoleak. If the exposure of the BT was adequate, we preferred an end-to-end anastomosis, but there was often too little space to permit one on the LCCA because of the arch aneurysm. In patients with large aneurysms, the exposure of the LCCA may have been so compromised that it was inadequate for expedient anastomoses. In such cases, we made an additional small incision in the left neck for the bypass to the LCCA.


Figure 2
View larger version (94K):
[in this window]
[in a new window]

  		Fig 2. Aortic arch de-branching (bifurcated graft).

 

Figure 3
View larger version (90K):
[in this window]
[in a new window]

  		Fig 3. Aortic arch de-branching (T-graft).

 
Endovascular Aortic Arch Repair
We selected commercial ESG devices according to length, required diameter, and anatomical findings. The ESG diameter was calculated from the largest proximal or distal neck diameter and an over-sizing factor of 10% to 15%. The ESG devices were implanted in the operating room under general anesthesia. Intraoperative angiography was performed using a breath-hold technique and a mobile C-arm intensifier. The ESGs were advanced under fluoroscopic guidance and deployed during systemic hypotension (blood pressure, 20 to 40 mm Hg) and rapid cardiac pacing (frequency, 180-220/min). We used latex balloons in patients with aortic aneurysms (Reliant balloon; Medtronic, Minneapolis, MN) to improve expansion for modeling the ESGs to the aortic wall.

We preferred a one-stage approach, especially in cases with tight aortic arches, as it was often impossible to bring the ESGs around tight aortic arches using femoral access, due to excessive resistance with the currently available ESGs. In such cases, antegrade ESG deployment (using a side limb sewn to the prosthesis) permitted the ESG navigation, even through very tight arches. If an antegrade approach was chosen to deploy the ESG, it was important that the ESG be advanced from the side arm of the ascending aortic graft into the ascending aorta without excessive mechanical force. If the ESG could not be easily advanced through the sternotomy incision, a small incision could be made in the right anterior chest. This would allow the ESG to be advanced with much less mechanical force.

With patients whose stent-landing zone were clearly distinguishable from external anatomic landmarks, and if the wire position in the correct lumen was transesophageal echocardiographically verifiable, we marked the planned ESG deployment site with radio-opaque thread markers in surgical 4 x 4 sponges. This enabled us to significantly reduce the need for angiographic contrast media use. The ESG could be deployed exactly at the planned site without pre-deployment angiography. Surgical clips are much less visible on fluoroscopy and are less suitable as external markers.


   Clinical Experience
Top
 Abstract
 Technology
 Technique
 Clinical Experience
Comment
 Disclosures and Freedom of...
 Footnotes
 References
 
We carried out EVAAR after aortic arch de-branching in 26 patients (Fig 4). Four patients died due to perioperative cardiovascular adverse events. No patient suffered from stroke or paraplegia. One patient who presented with a heavily-calcified ascending aorta underwent total arch re-routing due to multiple penetrating atherosclerotic ulcers; he experienced a temporary neurologic event most likely due to embolization during tangential clamping of the ascending aorta, which had resolved by the time he was discharged. We observed two minor adverse events: one patient with a separate aortic arch branch of the left vertebral artery suffered from type II endoleak and the other patient had a sternum infection.


Figure 4
View larger version (74K):
[in this window]
[in a new window]

  		Fig 4. Postoperative computed tomographic angiography after aortic arch de-branching and endovascular aortic arch repair.

 

   Comment
Top
 Abstract
 Technology
 Technique
 Clinical Experience
 Comment
Disclosures and Freedom of...
 Footnotes
 References
 
Experience with surgical bypass grafting in conjunction with EVAAR is limited. Reasons for this are the novelty of the combined endovascular and open surgical approach, and the paucity of patients with aortic arch disease who are potential candidates for this procedure. The endovascular method requires suitable "landing zones" (2 cm of normal aortic wall) for ESG fixation [5]. In aortic pathologies (including the aortic arch), surgical bypass grafting prior to EVAAR is necessary to prevent ischemic events. Such events can lead to neurologic complications, occlusive ischemia, or embolisms, and they occur centrally, such as in the brainstem or spinal cord, and peripherally (ie, arm ischemia) [4].

We propose an ascending aortic bi-carotid bypass using an inversed bifurcated prosthesis or an 8-mm and 10-mm T-graft for revascularizing the BT and LCCA in aortic arch pathologies involving the origin of these vessels. This method offers several advantages over conventional procedures (ie, avoidance of CPB and deep hypothermic circulatory arrest), even though its long-term durability remains unproven. We and others have demonstrated that additional transposition of the LSA or LSA to LCCA bypass before coverage of the LSA origin by an ESG is not necessary in all patients with normal supra-aortic vessels [3, 4, 6], nor is it necessary to bypass or transpose the LSA in patients with occlusive LSA disease, as they usually present collateral vessel development due to slow disease progression [7]. However, some patients do require additional transposition or bypass of the LSA to the LCCA (ie, those having undergone coronary artery bypass grafting with patent left internal mammary arteries, and those presenting with carotid or vertebral artery stenoses or anatomical variants of the subclavian, vertebral, or basilar arteries, or the circle of Willis [1, 8]). Another indication for transposing the LSA or for LCCA to LSA bypass surgery with proximal ligation is to prevent type II endoleaks with retrograde perfusion of the aneurysm sac or the false lumen in dissections [2]. In our previous investigation, we covered the LSA with ESGs without ligating the LSA, observing no type II endoleaks from the LSA during follow-up [4].

Byrne and colleagues [9] analyzed 143 extra-anatomical procedures for carotid and subclavian reconstruction. Indications for surgery were primarily occlusive or embolic disease. Most bypass grafts were made from polytetrafluoroethylene, and the 5-year patency rate was 92%. This study suggests that artificial bypass grafts can reveal excellent patency rates [9]. We used polyester prostheses in our series.

Technical Pitfalls and Safeguards
One of the main dangers associated with this procedure is the construction of the end-to-side ascending aortic anastomosis. In our method, we clamp the ascending aorta tangentially without using CPB, thus avoiding aortic cross clamping. Some authors see the need for CPB before they tangentially clamp the ascending aorta (ie, in patients with proximal ascending aortic aneurysms whose landing zone extends almost to the level of the sinotubular junction) [10].

It is extremely important that a large, atraumatic side-biting clamp be used for the ascending aorta, and that the blood pressure be lowered significantly so as to minimize the significant risk of ascending aortic dissection. After aortotomy, we prefer to sew the proximal side-to-end anastomosis on the ascending aorta first, before sewing the distal anastomosis on the supra-aortic vessels.

Undue forces on the ascending aortic anastomosis during antegrade ESG advancement constitute a real danger and can lead to disruption of the ascending anastomosis. If there is any doubt, a small incision in the right chest should be made to prevent the build-up of undue forces. Should significant bleeding from this anastomosis occur after ESG deployment, one must keep in mind that it has to be fixed without re-clamping the ascending aorta, since the ESG can not be clamped safely with a tangential clamp.

A single-stage approach allows for better arch access, and unorthodox solutions, such as control of the wire on both sides (ie, tooth-floss technique), which should advance the ESG across the aortic arch. A radio-opaque marker (such as the marker threads in surgical 4 x 4 sponges) can reduce the amount of contrast media used for such cases, potentially preventing potential renal complications.

For proper ESG placement, we recommend the use of rapid cardiac pacing and systemic hypotension. Under such optimum conditions, the expansion and placement of the ESGs can be controlled and precise. Adenosine before ESG placement has not yielded reproducible results in our hands, as there is great variation in the required dose and the interval to heart block.

In conclusion, we have presented a method for surgical de-branching of the aortic arch before completely covering it with ESGs, which is a procedure that can be carried out safely while avoiding significant pitfalls. This method makes both CPB and deep hypothermic circulatory arrest unnecessary, thereby having the potential to lower morbidity and mortality rates.


   Disclosures and Freedom of Investigation
Top
 Abstract
 Technology
 Technique
 Clinical Experience
 Comment
 Disclosures and Freedom of...
Footnotes
 References
 
The authors have no commercial association or sources of support that may pose a conflict of interest. In addition, the authors had full control of the study, methods used, outcome measurements, data analysis, and production of the written report.


   Footnotes
Top
 Abstract
 Technology
 Technique
 Clinical Experience
 Comment
 Disclosures and Freedom of...
 Footnotes
References
 
Disclaimer The Society of Thoracic Surgeons, the Southern Thoracic Surgical Association, and The Annals of Thoracic Surgery neither endorse nor discourage use of the new technology described in this article.

* The first two authors listed contributed equally to this article. Back


   References
Top
 Abstract
 Technology
 Technique
 Clinical Experience
 Comment
 Disclosures and Freedom of...
 Footnotes
 References
 

  1. Schoder M, Grabenwöger M, Hölzenbein T, et al. Endovascular repair of the thoracic aorta necessitating anchoring of the stent graft across the arch vessels J Thorac Cardiovasc Surg 2006;131:380-387.[Abstract/Free Full Text]
  2. Tiesenhausen K, Hausegger KA, Oberwalder P, et al. Left subclavian artery management in endovascular repair of thoracic aortic aneurysms and aortic dissections J Card Surg 2003;18:429-435.[Medline]
  3. Görich J, Asquan Y, Seifarth H, et al. Initial experience with intentional stent-graft coverage of the subclavian artery during endovascular thoracic aortic repairs J Endovasc Ther 2002;9:39-43.
  4. Weigang E, Luehr M, Harloff A, et al. Incidence of neurological complications following overstenting of the left subclavian artery Eur J Cardiothorac Surg 2007;31:628-636.[Abstract/Free Full Text]
  5. Caronno R, Piffaretti G, Tozzi M, Lomazzi C, Rivolta N, Castelli P. Intentional coverage of the left subclavian artery during endovascular stent graft repair for thoracic artery disease Surg Endosc 2006;20:915-918.[Medline]
  6. Hausegger KA, Oberwalder P, Tiesenhausen K, et al. Intentional left subclavian artery occlusion by thoracic aoertic stent-grafts without surgical transposition J Endovasc Ther 2001;8:472-476.[Medline]
  7. Ackermann H, Diener HC, Seboldt H, Huth C. Ultrasonographic follow-up of subclavian stenosis and occlusion: natural history and surgical treatment Stroke 1988;19:431-435.[Abstract/Free Full Text]
  8. Rehders TC, Petzsch M, Ince H, et al. Intentional occlusion of the left subclavian artery during stent-graft implantation in the thoracic aorta: risk and relevance J Endovasc Ther 2004;11:659-666.[Medline]
  9. Byrne J, Darling RC, Roddy SP, et al. Long term outcome for extra-anatomic arch reconstruction. An analysis of 143 procedures. Eur J Vasc Surg 2007;34:444-450.
  10. Szeto WY, Bavaria JE, Bowen FW, Woo EY, Fairman RM, Pochettino A. The hybrid total arch repair: brachiocephalic bypass and concomitant endovascular aortic arch stent graft placement J Card Surg 2007;22:97-102.[Medline]

Related Article

Invited Commentary
Grayson H. Wheatley, III
Ann. Thorac. Surg. 2009 87: 607. [Extract] [Full Text] [PDF]



This article has been cited by other articles:


Home page
 Ann. Thorac. Surg.Home page
A. Kulik, C. F. Castner, and N. T. Kouchoukos
Outcomes After Total Aortic Arch Replacement With Right Axillary Artery Cannulation and a Presewn Multibranched Graft
Ann. Thorac. Surg., September 1, 2011; 92(3): 889 - 897.
[Abstract] [Full Text] [PDF]

Home page
 Eur J Cardiothorac SurgHome page
M. Glauber, M. Murzi, P. Farneti, S. Bevilacqua, M. Mariani, A. Tognarelli, T. Gasbarri, and S. Berti
Aortic arch replacement with prophylactic aortic arch debranching during type A acute aortic dissection repair: initial experience with 23 patients
Eur J Cardiothorac Surg, August 1, 2011; 40(2): 418 - 423.
[Abstract] [Full Text] [PDF]

Home page
 Interact CardioVasc Thorac SurgHome page
E. Weigang, J. Parker, K. K. Gast, and C.-F. Vahl
Symptomatic atherosclerotic occlusive disease of all supra-aortic arch vessels treated with total aortic arch rerouting
Interact CardioVasc Thorac Surg, May 1, 2011; 12(5): 857 - 859.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
C. W. Lee, T. M. Beaver, C. T. Klodell Jr, P. J. Hess Jr, T. D. Martin, R. J. Feezor, and W. A. Lee
Arch Debranching Versus Elephant Trunk Procedures for Hybrid Repair of Thoracic Aortic Pathologies
Ann. Thorac. Surg., February 1, 2011; 91(2): 465 - 471.
[Abstract] [Full Text] [PDF]

Home page
 MMCTSHome page
J. Dumfarth, R. Gottardi, J. Holfeld, M. Schoder, T. Dziodzio, A. Juraszek, M. Hoebartner, G. Laufer, M. Grimm, and M. Czerny
Translocation of the supra-aortic vessels and stent grafting of the aortic arch
MMCTS, January 1, 2010; 2010(0311): mmcts.2008.003871 - mmcts.2008.003871.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
G. H. Wheatley III
Invited Commentary
Ann. Thorac. Surg., February 1, 2009; 87(2): 607 - 607.
[Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Ernst Weigang
Jack Parker
Martin Czerny
Ali A. Peivandi
Friedhelm Beyersdorf
Michael P. Siegenthaler
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Weigang, E.
Right arrow Articles by Siegenthaler, M. P.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Weigang, E.
Right arrow Articles by Siegenthaler, M. P.
Related Collections
Right arrow Great vessels
Right arrowRelated Article

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS