Korean Circ J.  2010 Aug;40(8):399-404. 10.4070/kcj.2010.40.8.399.

Combined Open and Endovascular Repair for Aortic Arch Pathology

• Kang WC
• Shin EK
• Ahn TH
• Lee KH
• Moon CI
• Han SH
• Park CH
• Park KY
• Kang JM
• Kim JH

• KMID: 2145532
• DOI: http://doi.org/10.4070/kcj.2010.40.8.399

Abstract

BACKGROUND AND OBJECTIVES
We describe our experience with combined open and endovascular repair in patients who have aortic arch pathology.
SUBJECTS AND METHODS
This study is a retrospective analysis of 7 patients who underwent combined open and endovascular repair for aortic arch pathology. Medical records and radiographic information were reviewed.
RESULTS
A total of 7 consecutive patients (5 men, 71.4%) underwent thoracic stent graft implantation. The mean age was 59.9+/-16.7 years. The indication for endovascular repair was aneurysmal degeneration in 5 patients, and rupture or impending rupture in 2 patients. In all 7 cases, supra-aortic transposition of the great vessels was performed successfully. Stent graft implantation was achieved in all cases. Surgical exposure of the access vessel was necessary in 2 patients. A total of 9 stent grafts were implanted (3 stent grafts in one patient). The Seal thoracic and the Valiant endovascular stent graft were implanted in 6 patients and 1 patient, respectively. There were no post-procedure deaths or neurologic complications. In 2 patients, bleeding and injury of access vessel were noted after the procedure. Postoperative endoleak was noted in 1 patient. One patient died at 10 months after the procedure due to a newly developed ascending aortic dissection. No patients required secondary intervention during the follow-up period. The aortic diameter decreased in 4 patients. In 3 patients, including 1 patient with endoleak, there was no change in aortic diameter.
CONCLUSION
Our experience suggests that combined open and endovascular repair for aortic arch pathology is safe and effective, with few complications.

Keyword

Prostheses and implants; Aortic disease; Aortic aneurysm

MeSH Terms

Aneurysm
Aorta, Thoracic
Aortic Aneurysm
Aortic Diseases
Endoleak
Follow-Up Studies
Glycosaminoglycans
Hemorrhage
Humans
Male
Medical Records
Prostheses and Implants
Retrospective Studies
Rupture
Stents
Transplants
Glycosaminoglycans

Figure

• 

  Fig. 1 Reconstructive three-dimensional computed tomography showed extensive aortic aneurysm involving the aortic arch and proximal descending thoracic aorta (A and B). Y-shaped bypass surgery with a prosthetic graft, to connect the aorta to the BA and the LCCA, was performed (white arrow) and followed by end-to-side anastomosis of the LCCA and LSCA (open arrow) (C and D). After supra-aortic transposition of the great vessels, 3 Valiant stent grafts were implanted from the ascending aorta to the descending thoracic aorta in a telescopic fashion to exclude extensive aortic aneurysm (E and F). BA: brachiocephalic artery, LCCA: left common carotid artery, LSCA: left subclavian artery.

Reference

1. 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. discussion 1891-4.

2. Harrington DK, Walker AS, Kaukuntla H, et al. Selective antegrade cerebral perfusion attenuates brain metabolic deficit in aortic arch surgery: a prospective randomized trial. Circulation. 2004. 110:11 Suppl 1. II231–II236.

3. 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.

4. Gottardi R, Funovics M, Eggers N, et al. Supra-aortic transposition for combined vascular and endovascular repair of aortic arch pathology. Ann Thorac Surg. 2008. 86:1524–1529.

5. Joung B, Kang WC, Lee SH, et al. Favorable late outcome of endovascular abdominal aortic aneurysm repair. Korean Circ J. 2003. 33:797–804.

6. Kim BK, Park S, Ko YG, et al. Immediate and mid-term outcomes of the endovascular stent-graft treatment of abdominal aortic aneurysm. Korean Circ J. 2005. 35:583–590.

7. Stone DH, Brewster DC, Kwolek CJ, et al. Stent-graft versus open-surgical repair of the thoracic aorta: mid-term results. J Vasc Surg. 2006. 44:1188–1197.

8. Bavaria JE, Appoo JJ, Makaroun MS, Verter J, Yu ZF, Mitchell RS. Endovascular stent grafting versus open surgical repair of descending thoracic aortic aneurysms in low-risk patients: a multicenter comparative trial. J Thorac Cardiovasc Surg. 2007. 133:369–377.

9. 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.

10. Czerny M, Fleck T, Zimpfer D, et al. Combined repair of an aortic arch aneurysm by sequential transposition of the supra-aortic branches and endovascular stent-graft placement. J Thorac Cardiovasc Surg. 2003. 126:916–918.

11. 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.

12. 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.

13. 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.

14. Lee WA, Brown MP, Nelson PR, Huber TS, Seeger JM. Midterm outcomes of femoral arteries after percutaneous endovascular aortic repair using the Preclose technique. J Vasc Surg. 2008. 47:919–923.

15. 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.

16. Czerny M, Cejna M, Hutschala D, et al. Stent-graft placement in atherosclerotic descending thoracic aortic aneurysms: midterm results. J Endovasc Ther. 2004. 11:26–32.

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.

18. Wheatley 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.

19. Hughes GC, Nienaber JJ, Bush EL, Daneshmand MA, McCann RL. Use of custom Dacron branch grafts for "hybrid" aortic debranching during endovascular repair of thoracic and thoracoabdominal aortic aneurysms. J Thorac Cardiovasc Surg. 2008. 136:21–28.

20. 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.

21. Saleh HM, Inglese L. Combined surgical and endovascular treatment of aortic arch aneurysms. J Vasc Surg. 2006. 44:460–466.

22. Kato N, Shimono T, Hirano T, et al. Midterm results of stent-graft repair of acute and chronic aortic dissection with descending tear: the complication-specific approach. J Thorac Cardiovasc Surg. 2002. 124:306–312.