© 2014 Wiley Periodicals, Inc.
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DISEASES OF THE AORTA SURGICAL TECHNIQUE ___________________________________________________________
Hybrid Procedure for Acute Stanford Type A Aortic Dissection with Aberrant Right Subclavian Artery Changwei Ren, M.D., Lizhong Sun, M.D., Lianjun Huang, M.D., Yongqiang Lai, M.D., Sheng Yang, M.D., and Shangdong Xu, M.D. Department of Cardiovascular Surgery Center, Beijing Anzhen Hospital Affiliated to Capital Medical University, Beijing, China ABSTRACT Aberrant right subclavian artery (ARSA) is an uncommon congenital vascular abnormality. Acute Stanford type A aortic dissection with ARSA is rare. We report a strategy for Stanford type A aortic dissection with ARSA. The ascending aorta and the total aortic arch were replaced and a frozen elephant trunk was implanted into the descending aorta. The right subclavian artery was reconstructed with the perfusion branch of a four-branch prosthetic graft. Two weeks later, the proximal part of the ARSA was sealed with a vascular plug. doi: 10.1111/jocs.12386 (J Card Surg 2015;30:274–275) Aberrant right subclavian artery (ARSA) is an uncommon congenital vascular abnormality. Acute Stanford type A aortic dissection with ARSA is rare. We report a strategy (Fig. 1) for Stanford type A aortic dissection with ARSA. The study protocol was approved by the Institutional Review Board of the Capital Medical University (Beijing, China). SURGICAL TECHNIQUE A 46-year-old hypertensive male was admitted with sudden chest pain. Computed tomography (CT) scan demonstrated type A aortic dissection from the ascending aorta to the both iliac arteries and ARSA was found simultaneously. Emergent aortic repair was performed. The right axillary artery was prepared for cannulation and then a median sternotomy was performed. Cardiopulmonary bypass (CPB) was initiated after right atrium cannulation with a two-staged single venous cannula. The aortic valve was normal. The intimal tear was located in the ascending aorta and the ascending aorta was replaced with a 28-mm prosthetic graft (Boston Scientific, Inc., Boston, MA, USA) during systemic cooling. When the nasal temperature reached 20 8C, the left subclavian artery and bilateral
common carotid arteries were clamped and the axillary artery perfusion was stopped. The aortic arch was opened and unilateral antegrade cerebral perfusion (5 mL/ kg) was performed through the right common carotid artery. A frozen elephant trunk (MicroPort Medical Co Ltd, Shanghai, China) was deployed through the incision of the aortic arch. After the anastomosis of the proximal end of the frozen elephant trunk with the four-branch prosthetic graft was completed, the perfusion of the lower body was initiated via the perfusion branch of the prosthetic graft. The left common carotid artery, right common carotid artery, proximal aortic stump, and left subclavian artery were anastomosed sequentially to the branches of the prosthetic graft. After weaning off CPB, the right subclavian artery was reconstructed with the perfusion branch of the four-branch prosthetic graft. Two weeks later, the endovascular procedure was performed under local anesthesia. Selected digital subtraction angiography (DSA) via the right brachial artery showed that partial blood flow entered the false lumen from the ARSA (Fig. 2). A plug (P1416, Huayishengjie, China) was implanted into the proximal part of the ARSA. After that, DSA showed the bypass graft was patent and the proximal part of the ARSA originating from the descending aorta was sealed completely. No endoleak was found (Fig. 3). The patient was discharged home uneventfully seven days after the endovascular procedure.
Conflict of interest: The authors acknowledge no conflict of interest in the submission.
DISCUSSION
Address for correspondence: Shangdong Xu, M.D., Department of Cardiovascular Surgery Center, Beijing Anzhen Hospital Affiliated to Capital Medical University, 36 Wuluju Chaoyang District, Beijing 100029, China. Fax: þ86-10-64456576; e-mail: [email protected]
ARSA is a congenital variation of the aortic arch, with a reported incidence of 0.2–1.8%.1 It can result in complications if the ARSA was used for unilateral
J CARD SURG 2015;30:274–275
Figure 1. General view of the procedure. The ascending aorta and the total aortic arch were replaced; meanwhile, we implanted a frozen elephant trunk into the descending aorta and reconstructed the right subclavian artery with a end-to-side bypass (left arrow) with the perfusion branch of a four-branch prosthetic graft. Two weeks later, we treated the patient endovascularly with a vascular plug (right arrow) implanted into the proximal part of the aberrant right subclavian artery to seal the entry to false lumen of the descending aorta.
antegrade cerebral perfusion during aortic arch repair procedures.2 There are several reports regarding acute Stanford type A aortic dissection with ARSA.2–5 Different strategies including ascending aorta or total arch replacement were adopted by the authors but without reconstruction of the ARSA and implantation of a frozen elephant trunk into the descending aorta. For this case, in addition to the ascending aorta and the total arch repair, a frozen elephant trunk was deployed to seal the tear in the descending aorta and to promote the formation of thrombus in the false lumen. Unavoidably the origin of the ARSA was blocked by the frozen elephant trunk. The reconstruction of the right subclavian artery was completed after the arch repair.
REN, ET AL. A HYBRID PROCEDURE
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Figure 3. DSA showed the proximal part of the aberrant right subclavian artery was sealed completely. No endoleak was found (arrow).
However, we found flow from the ARSA into the false lumen of the proximal part of the descending aorta during the DSA examination two weeks postoperatively. This flow from the ARSA might hinder the formation of thrombus in the false lumen and result in further dilation and potential rupture of the descending aorta.6 The ARSA was located in the posterior aspect of the aortic arch, so it was too difficult to ligate at the time of surgery. Furthermore, the blood flow to the right vertebral artery would be blocked if the ligation at the proximal part of the axillary artery was performed. So the proximal part of the ARSA was sealed by a vascular plug. The blood flow of the right axillary artery and right vertebral artery is now derived from the bypass graft. Our two-stage strategy decreased the ischemic and cardiopulmonary bypass time, allowing for better recovery of renal function. REFERENCES
Figure 2. During the endovascular procedure, selected DSA via the right brachial artery (left arrow) showed the blood can flow back (right arrow) from the aberrant right subclavian artery to false lumen.
1. Freed K, Low VH: The aberrant subclavian artery. Am J Roentgenol 1997;168:481–484. 2. Bektas B, Serkan S, Cengiz C, et al: Aberrant right subclavian artery and axillary artery cannulation in type A aortic dissection repair. Ann Thorac Surg 2013;96:e1–e2. 3. Kikuchi K, Makuuchi H, Oono M, et al: Surgery for aortic dissection involving an aberrant right subclavian artery. Jpn J Thorac Cardiovasc Surg 2005;53:632–634. 4. Furukawa H, Takemura T, Ohno H, et al: Stanford type A acute aortic dissection involving an aberrant right subclavian artery—A successful operative case (Engabstr). Nippon Kyobu Geka Gakkai Zasshi 1995;43:533–537. 5. Misumi T, Kudo M, Ito T, et al: Acute aortic dissection involving an aberrant right subclavian artery. Jpn J Thorac Cardiovasc Surg 2002;50:119–121. 6. LiZhong S, RuiDong Q, JunMing Z, et al: Total arch replacement combined with stented elephant trunk implantation. Circulation 2011;123:971–978.
Copyright of Journal of Cardiac Surgery is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
274
DISEASES OF THE AORTA SURGICAL TECHNIQUE ___________________________________________________________
Hybrid Procedure for Acute Stanford Type A Aortic Dissection with Aberrant Right Subclavian Artery Changwei Ren, M.D., Lizhong Sun, M.D., Lianjun Huang, M.D., Yongqiang Lai, M.D., Sheng Yang, M.D., and Shangdong Xu, M.D. Department of Cardiovascular Surgery Center, Beijing Anzhen Hospital Affiliated to Capital Medical University, Beijing, China ABSTRACT Aberrant right subclavian artery (ARSA) is an uncommon congenital vascular abnormality. Acute Stanford type A aortic dissection with ARSA is rare. We report a strategy for Stanford type A aortic dissection with ARSA. The ascending aorta and the total aortic arch were replaced and a frozen elephant trunk was implanted into the descending aorta. The right subclavian artery was reconstructed with the perfusion branch of a four-branch prosthetic graft. Two weeks later, the proximal part of the ARSA was sealed with a vascular plug. doi: 10.1111/jocs.12386 (J Card Surg 2015;30:274–275) Aberrant right subclavian artery (ARSA) is an uncommon congenital vascular abnormality. Acute Stanford type A aortic dissection with ARSA is rare. We report a strategy (Fig. 1) for Stanford type A aortic dissection with ARSA. The study protocol was approved by the Institutional Review Board of the Capital Medical University (Beijing, China). SURGICAL TECHNIQUE A 46-year-old hypertensive male was admitted with sudden chest pain. Computed tomography (CT) scan demonstrated type A aortic dissection from the ascending aorta to the both iliac arteries and ARSA was found simultaneously. Emergent aortic repair was performed. The right axillary artery was prepared for cannulation and then a median sternotomy was performed. Cardiopulmonary bypass (CPB) was initiated after right atrium cannulation with a two-staged single venous cannula. The aortic valve was normal. The intimal tear was located in the ascending aorta and the ascending aorta was replaced with a 28-mm prosthetic graft (Boston Scientific, Inc., Boston, MA, USA) during systemic cooling. When the nasal temperature reached 20 8C, the left subclavian artery and bilateral
common carotid arteries were clamped and the axillary artery perfusion was stopped. The aortic arch was opened and unilateral antegrade cerebral perfusion (5 mL/ kg) was performed through the right common carotid artery. A frozen elephant trunk (MicroPort Medical Co Ltd, Shanghai, China) was deployed through the incision of the aortic arch. After the anastomosis of the proximal end of the frozen elephant trunk with the four-branch prosthetic graft was completed, the perfusion of the lower body was initiated via the perfusion branch of the prosthetic graft. The left common carotid artery, right common carotid artery, proximal aortic stump, and left subclavian artery were anastomosed sequentially to the branches of the prosthetic graft. After weaning off CPB, the right subclavian artery was reconstructed with the perfusion branch of the four-branch prosthetic graft. Two weeks later, the endovascular procedure was performed under local anesthesia. Selected digital subtraction angiography (DSA) via the right brachial artery showed that partial blood flow entered the false lumen from the ARSA (Fig. 2). A plug (P1416, Huayishengjie, China) was implanted into the proximal part of the ARSA. After that, DSA showed the bypass graft was patent and the proximal part of the ARSA originating from the descending aorta was sealed completely. No endoleak was found (Fig. 3). The patient was discharged home uneventfully seven days after the endovascular procedure.
Conflict of interest: The authors acknowledge no conflict of interest in the submission.
DISCUSSION
Address for correspondence: Shangdong Xu, M.D., Department of Cardiovascular Surgery Center, Beijing Anzhen Hospital Affiliated to Capital Medical University, 36 Wuluju Chaoyang District, Beijing 100029, China. Fax: þ86-10-64456576; e-mail: [email protected]
ARSA is a congenital variation of the aortic arch, with a reported incidence of 0.2–1.8%.1 It can result in complications if the ARSA was used for unilateral
J CARD SURG 2015;30:274–275
Figure 1. General view of the procedure. The ascending aorta and the total aortic arch were replaced; meanwhile, we implanted a frozen elephant trunk into the descending aorta and reconstructed the right subclavian artery with a end-to-side bypass (left arrow) with the perfusion branch of a four-branch prosthetic graft. Two weeks later, we treated the patient endovascularly with a vascular plug (right arrow) implanted into the proximal part of the aberrant right subclavian artery to seal the entry to false lumen of the descending aorta.
antegrade cerebral perfusion during aortic arch repair procedures.2 There are several reports regarding acute Stanford type A aortic dissection with ARSA.2–5 Different strategies including ascending aorta or total arch replacement were adopted by the authors but without reconstruction of the ARSA and implantation of a frozen elephant trunk into the descending aorta. For this case, in addition to the ascending aorta and the total arch repair, a frozen elephant trunk was deployed to seal the tear in the descending aorta and to promote the formation of thrombus in the false lumen. Unavoidably the origin of the ARSA was blocked by the frozen elephant trunk. The reconstruction of the right subclavian artery was completed after the arch repair.
REN, ET AL. A HYBRID PROCEDURE
275
Figure 3. DSA showed the proximal part of the aberrant right subclavian artery was sealed completely. No endoleak was found (arrow).
However, we found flow from the ARSA into the false lumen of the proximal part of the descending aorta during the DSA examination two weeks postoperatively. This flow from the ARSA might hinder the formation of thrombus in the false lumen and result in further dilation and potential rupture of the descending aorta.6 The ARSA was located in the posterior aspect of the aortic arch, so it was too difficult to ligate at the time of surgery. Furthermore, the blood flow to the right vertebral artery would be blocked if the ligation at the proximal part of the axillary artery was performed. So the proximal part of the ARSA was sealed by a vascular plug. The blood flow of the right axillary artery and right vertebral artery is now derived from the bypass graft. Our two-stage strategy decreased the ischemic and cardiopulmonary bypass time, allowing for better recovery of renal function. REFERENCES
Figure 2. During the endovascular procedure, selected DSA via the right brachial artery (left arrow) showed the blood can flow back (right arrow) from the aberrant right subclavian artery to false lumen.
1. Freed K, Low VH: The aberrant subclavian artery. Am J Roentgenol 1997;168:481–484. 2. Bektas B, Serkan S, Cengiz C, et al: Aberrant right subclavian artery and axillary artery cannulation in type A aortic dissection repair. Ann Thorac Surg 2013;96:e1–e2. 3. Kikuchi K, Makuuchi H, Oono M, et al: Surgery for aortic dissection involving an aberrant right subclavian artery. Jpn J Thorac Cardiovasc Surg 2005;53:632–634. 4. Furukawa H, Takemura T, Ohno H, et al: Stanford type A acute aortic dissection involving an aberrant right subclavian artery—A successful operative case (Engabstr). Nippon Kyobu Geka Gakkai Zasshi 1995;43:533–537. 5. Misumi T, Kudo M, Ito T, et al: Acute aortic dissection involving an aberrant right subclavian artery. Jpn J Thorac Cardiovasc Surg 2002;50:119–121. 6. LiZhong S, RuiDong Q, JunMing Z, et al: Total arch replacement combined with stented elephant trunk implantation. Circulation 2011;123:971–978.
Copyright of Journal of Cardiac Surgery is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
