2090
CANAUD ET AL COMPLETE ENDOVASCULAR AORTIC ARCH RECONSTRUCTION
ADULT CARDIAC
plastic tubing and other substrates bear little resemblance to basic tissue properties, such as compliance, of the human aorta. One weakness of our model is that stentgrafts were deployed within nonaneurysmal aortas. Thus, the “seal” zone for the aortic graft is the entire length of the graft, and therefore there is no room for a type I endoleak to appear. Additionally, retrograde fenestration would be more difficult in the setting of an aneurysm in which major portions of the stent-graft may not be immediately adjacent to the aortic wall. Therefore, the model used more closely parallels traumatic aortic injury or an acute type B dissection rather than an aneurysm. In conclusion, this study confirms the feasibility and reproducibility of performing complete endovascular arch reconstruction by in situ retrograde fenestration. This approach would produce more accurate fenestrations, with less reliance on preoperative imaging. It could potentially broaden availability and decrease costs through the use of noncustomized stent-grafts. Furthermore, retrograde perforation avoids the difficulties of side branch catheterization and the high inherent risk of cerebral embolism.
References 1. Estrera AL, Miller CC 3rd, Madisetty J, et al. Ascending and transverse aortic arch repair: the impact of glomerular filtration rate on mortality. Ann Surg 2008;247:524–9. 2. Canaud L, Hireche K, Berthet JP, Branchereau P, Marty-An e C, Alric P. Endovascular repair of aortic arch lesions in high-risk patients or after previous aortic surgery: midterm results. J Thorac Cardiovasc Surg 2010;140: 52–8. 3. Abraham CZ, Lioupis C. Treatment of aortic arch aneurysms with a modular transfemoral multibranched
Ann Thorac Surg 2014;98:2086–91
4.
5. 6.
7. 8. 9.
10.
11. 12.
13.
14.
stent-graft: initial experience. J Thorac Cardiovasc Surg 2013;145:110–7. Canaud L, Alric P, Laurent M, et al. Proximal fixation of thoracic stent-grafts as a function of oversizing and increasing aortic arch angulation in human cadaveric aortas. J Endovasc Ther 2008;15:326–34. Greenberg RK, Lytle B. Endovascular repair of thoracoabdominal aneurysms. Circulation 2008;117:2288–96. McWilliams RG, Fearn SJ, Harris PL, Hartley D, Semmens JB, Lawrence-Brown MM. Retrograde fenestration of endoluminal grafts from target vessels: feasibility, technique, and potential usage. J Endovasc Ther 2003;10:946–52. Sonesson B, Resch T, Allers M, Malina M. Endovascular total aortic arch replacement by in situ stent graft fenestration technique. J Vasc Surg 2009;49:1589–91. Saari P, Manninen H. Fenestration of aortic stent grafts-in vitro tests using various device combinations. J Vasc Interv Radiol 2011;22:89–94. Riga CV, Bicknell CD, Basra M, Hamady M, Cheshire NJ. In vitro fenestration of aortic stent-grafts: implications of puncture methods for in situ fenestration durability. J Endovasc Ther 2013;20:536–43. Redlinger RE Jr, Ahanchi SS, Panneton JM. In situ laser fenestration during emergent thoracic endovascular aortic repair is an effective method for left subclavian artery revascularization. J Vasc Surg 2013;58:1171–7. Walterbusch G, Oelert H, Borst HG. Restoration of cerebral blood flow by extraanatomic bypass in acute aortic dissection. Thorac Cardiovasc Surg 1984;32:381–2. Sch€ onholz C, Ikonomidis JS, Hannegan C, Mendaro E. Bailout percutaneous external shunt to restore carotid flow in a patient with acute type A aortic dissection and carotid occlusion. J Endovasc Ther 2008;15:639–42. Joyeux F, Canaud L, Hireche K, Berthet JP, Marty-Ane C, Alric P. Temporary extra-anatomic brain perfusion followed by total rerouting of the supra-aortic vessels for hybrid repair of a ruptured aortic arch aneurysm. J Vasc Surg 2011;54: 1145–7. Lownie SP, Menkis AH, Craen RA, Mezon B, MacDonald J, Steinman DA. Extracorporeal femoral to carotid artery perfusion in selective brain cooling for a giant aneurysm. Case report. J Neurosurg 2004;100:343–7.
INVITED COMMENTARY For about 60 years, surgical procedures on the aortic arch have been performed by different approaches with varied outcomes. The risks of death and stroke range from 1% to 12% and from 1% to 15%, respectively. Open surgical arch replacement continues to be done with cooling and circulatory arrest, but the optimum technique, the temperature, and the role of adjuvant brain perfusion remain debatable issues. Furthermore, the results of either arch debranching and stenting or custom-branched grafts have generally not been better compared with classic open operations; indeed, they are often worse. The predictors of outcome, however, that are certain include urgency of operation, rupture of the arch, older age, and cardiopulmonary bypass time. In this report, Canaud and colleagues [1] have built on their own and other authors’ experiences to develop a cadaver model for replacing the aortic arch. They have shown that, given complex angulation and size changes in the aortic arch, it is still feasible to place an aortic arch stent (with likely cardiopulmonary bypass) across the Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier
arch, and they insert retrograde bridging stent grafts from the greater arch arteries back into the aortic arch stent graft. This novel approach should be particularly useful in those patients at greatest risk of adverse events, namely, patients who are elderly, require urgent operations, have aortic arch ruptures, or have some combination of these conditions. The authors used two currently approved aortic devices along with commercially available needles, wires, balloons, and a balloon expandable covered stent for the branches. As they have pointed out, one advantage of these devices is that they are all readily available “off the shelf.” With their model, they have demonstrated technical feasibility and no endoleaks on initial fluoroscopy. They are to be congratulated for creating a fine pulsatile model in fresh human aortas to mimic performance of the procedure. Of course, additional testing of this approach will be needed before its wider application in patients. For example, the more proximal aorta, arch, and arch branches are subject to great continuous hemodynamic
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.08.004
CANAUD ET AL COMPLETE ENDOVASCULAR AORTIC ARCH RECONSTRUCTION
forces. Much greater cardiac and respiratory motion is applied to these systems in vivo in a pathologic aorta than is seen in other segments of the aorta, and certainly more than was demonstrated in the model described here. How these forces over time will affect the durability of such a repair needs to be better understood. A caveat remains that industry-sponsored analyses of branched graft systems have demonstrated the potential for device fracture over time with several of the currently available devices placed into wear testing systems. The commercially available aortic stent grafts are not designed to be placed within the 270 of curvature of the aortic arch. Furthermore, if these engineering issues are not properly understood and accounted for, the displacement forces directed toward these devices in the proximal aorta may also lead to both branch collapse and occlusion. The continued use of hybrid approaches and the exploration of other novel techniques for arch repair highlight the need for patient-specific and disease-specific device design. This may be best accomplished when clinician investigators partner with industry. However, in an aging population with emergency indications for repair,
2091
operators who treat them find it difficult to wait. Canaud and colleagues have taken an important step in the development of a promising technique. These and other investigators’ outcomes for stenting the total arch in humans after the first in man report by Sonesson and colleagues [2] will be followed with interest. Lars G. Svensson, MD, PhD Eric Roselli, MD Aortic Center Cleveland Clinic 9500 Euclid Ave, J4-1 Cleveland, OH 44195 e-mail: [email protected]
References 1. Canaud L, Faure E, Branchereau P, Ozdemir BA, MartyAn e C, Alric P. Experimental evaluation of complete endovascular arch reconstruction by in situ retrograde fenestration. Ann Thorac Surg 2014;98:2086–91. 2. Sonesson B, Resch T, Allers M, Malina M. Endovascular total aortic arch replacement by in situ stent graft fenestration technique. J Vasc Surg 2009;49:1589–91.
ADULT CARDIAC
Ann Thorac Surg 2014;98:2086–91
CANAUD ET AL COMPLETE ENDOVASCULAR AORTIC ARCH RECONSTRUCTION
ADULT CARDIAC
plastic tubing and other substrates bear little resemblance to basic tissue properties, such as compliance, of the human aorta. One weakness of our model is that stentgrafts were deployed within nonaneurysmal aortas. Thus, the “seal” zone for the aortic graft is the entire length of the graft, and therefore there is no room for a type I endoleak to appear. Additionally, retrograde fenestration would be more difficult in the setting of an aneurysm in which major portions of the stent-graft may not be immediately adjacent to the aortic wall. Therefore, the model used more closely parallels traumatic aortic injury or an acute type B dissection rather than an aneurysm. In conclusion, this study confirms the feasibility and reproducibility of performing complete endovascular arch reconstruction by in situ retrograde fenestration. This approach would produce more accurate fenestrations, with less reliance on preoperative imaging. It could potentially broaden availability and decrease costs through the use of noncustomized stent-grafts. Furthermore, retrograde perforation avoids the difficulties of side branch catheterization and the high inherent risk of cerebral embolism.
References 1. Estrera AL, Miller CC 3rd, Madisetty J, et al. Ascending and transverse aortic arch repair: the impact of glomerular filtration rate on mortality. Ann Surg 2008;247:524–9. 2. Canaud L, Hireche K, Berthet JP, Branchereau P, Marty-An e C, Alric P. Endovascular repair of aortic arch lesions in high-risk patients or after previous aortic surgery: midterm results. J Thorac Cardiovasc Surg 2010;140: 52–8. 3. Abraham CZ, Lioupis C. Treatment of aortic arch aneurysms with a modular transfemoral multibranched
Ann Thorac Surg 2014;98:2086–91
4.
5. 6.
7. 8. 9.
10.
11. 12.
13.
14.
stent-graft: initial experience. J Thorac Cardiovasc Surg 2013;145:110–7. Canaud L, Alric P, Laurent M, et al. Proximal fixation of thoracic stent-grafts as a function of oversizing and increasing aortic arch angulation in human cadaveric aortas. J Endovasc Ther 2008;15:326–34. Greenberg RK, Lytle B. Endovascular repair of thoracoabdominal aneurysms. Circulation 2008;117:2288–96. McWilliams RG, Fearn SJ, Harris PL, Hartley D, Semmens JB, Lawrence-Brown MM. Retrograde fenestration of endoluminal grafts from target vessels: feasibility, technique, and potential usage. J Endovasc Ther 2003;10:946–52. Sonesson B, Resch T, Allers M, Malina M. Endovascular total aortic arch replacement by in situ stent graft fenestration technique. J Vasc Surg 2009;49:1589–91. Saari P, Manninen H. Fenestration of aortic stent grafts-in vitro tests using various device combinations. J Vasc Interv Radiol 2011;22:89–94. Riga CV, Bicknell CD, Basra M, Hamady M, Cheshire NJ. In vitro fenestration of aortic stent-grafts: implications of puncture methods for in situ fenestration durability. J Endovasc Ther 2013;20:536–43. Redlinger RE Jr, Ahanchi SS, Panneton JM. In situ laser fenestration during emergent thoracic endovascular aortic repair is an effective method for left subclavian artery revascularization. J Vasc Surg 2013;58:1171–7. Walterbusch G, Oelert H, Borst HG. Restoration of cerebral blood flow by extraanatomic bypass in acute aortic dissection. Thorac Cardiovasc Surg 1984;32:381–2. Sch€ onholz C, Ikonomidis JS, Hannegan C, Mendaro E. Bailout percutaneous external shunt to restore carotid flow in a patient with acute type A aortic dissection and carotid occlusion. J Endovasc Ther 2008;15:639–42. Joyeux F, Canaud L, Hireche K, Berthet JP, Marty-Ane C, Alric P. Temporary extra-anatomic brain perfusion followed by total rerouting of the supra-aortic vessels for hybrid repair of a ruptured aortic arch aneurysm. J Vasc Surg 2011;54: 1145–7. Lownie SP, Menkis AH, Craen RA, Mezon B, MacDonald J, Steinman DA. Extracorporeal femoral to carotid artery perfusion in selective brain cooling for a giant aneurysm. Case report. J Neurosurg 2004;100:343–7.
INVITED COMMENTARY For about 60 years, surgical procedures on the aortic arch have been performed by different approaches with varied outcomes. The risks of death and stroke range from 1% to 12% and from 1% to 15%, respectively. Open surgical arch replacement continues to be done with cooling and circulatory arrest, but the optimum technique, the temperature, and the role of adjuvant brain perfusion remain debatable issues. Furthermore, the results of either arch debranching and stenting or custom-branched grafts have generally not been better compared with classic open operations; indeed, they are often worse. The predictors of outcome, however, that are certain include urgency of operation, rupture of the arch, older age, and cardiopulmonary bypass time. In this report, Canaud and colleagues [1] have built on their own and other authors’ experiences to develop a cadaver model for replacing the aortic arch. They have shown that, given complex angulation and size changes in the aortic arch, it is still feasible to place an aortic arch stent (with likely cardiopulmonary bypass) across the Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier
arch, and they insert retrograde bridging stent grafts from the greater arch arteries back into the aortic arch stent graft. This novel approach should be particularly useful in those patients at greatest risk of adverse events, namely, patients who are elderly, require urgent operations, have aortic arch ruptures, or have some combination of these conditions. The authors used two currently approved aortic devices along with commercially available needles, wires, balloons, and a balloon expandable covered stent for the branches. As they have pointed out, one advantage of these devices is that they are all readily available “off the shelf.” With their model, they have demonstrated technical feasibility and no endoleaks on initial fluoroscopy. They are to be congratulated for creating a fine pulsatile model in fresh human aortas to mimic performance of the procedure. Of course, additional testing of this approach will be needed before its wider application in patients. For example, the more proximal aorta, arch, and arch branches are subject to great continuous hemodynamic
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.08.004
CANAUD ET AL COMPLETE ENDOVASCULAR AORTIC ARCH RECONSTRUCTION
forces. Much greater cardiac and respiratory motion is applied to these systems in vivo in a pathologic aorta than is seen in other segments of the aorta, and certainly more than was demonstrated in the model described here. How these forces over time will affect the durability of such a repair needs to be better understood. A caveat remains that industry-sponsored analyses of branched graft systems have demonstrated the potential for device fracture over time with several of the currently available devices placed into wear testing systems. The commercially available aortic stent grafts are not designed to be placed within the 270 of curvature of the aortic arch. Furthermore, if these engineering issues are not properly understood and accounted for, the displacement forces directed toward these devices in the proximal aorta may also lead to both branch collapse and occlusion. The continued use of hybrid approaches and the exploration of other novel techniques for arch repair highlight the need for patient-specific and disease-specific device design. This may be best accomplished when clinician investigators partner with industry. However, in an aging population with emergency indications for repair,
2091
operators who treat them find it difficult to wait. Canaud and colleagues have taken an important step in the development of a promising technique. These and other investigators’ outcomes for stenting the total arch in humans after the first in man report by Sonesson and colleagues [2] will be followed with interest. Lars G. Svensson, MD, PhD Eric Roselli, MD Aortic Center Cleveland Clinic 9500 Euclid Ave, J4-1 Cleveland, OH 44195 e-mail: [email protected]
References 1. Canaud L, Faure E, Branchereau P, Ozdemir BA, MartyAn e C, Alric P. Experimental evaluation of complete endovascular arch reconstruction by in situ retrograde fenestration. Ann Thorac Surg 2014;98:2086–91. 2. Sonesson B, Resch T, Allers M, Malina M. Endovascular total aortic arch replacement by in situ stent graft fenestration technique. J Vasc Surg 2009;49:1589–91.
ADULT CARDIAC
Ann Thorac Surg 2014;98:2086–91
