VASCULAR IMAGES
Total debranching thoracic endovascular aortic arch repair with inflow from the descending thoracic aorta Yasunori Iida, MD, PhD,a Tsutomu Ito, MD, PhD,a Takahiko Misumi, MD, PhD,a and Hideyuki Shimizu, MD, PhD,b Kanagawa and Tokyo, Japan A 71-year-old man with a 65-mm aortic arch aneurysm was at high risk for open surgery because of previous coronary artery bypass grafting and abdominal prosthetic graft replacement. Two debranching thoracic endovascular aortic repair (TEVAR) with a right subclavian artery inflow was abandoned because computed tomography imaging showed a brachiocephalic artery atherosclerotic lesion (A). The access route showed a strong kinking at the terminal aorta (B). Total debranching TEVAR with descending aorta inflow through left thoracotomy was performed. Firstly, with the patient supine, the arch vessel was debranched using a ringed expanded polytetrafluoroethylene graft (W. L. Gore & Associates, Flagstaff, Ariz) and anastomosed end-to-side to the subclavian arteries and end-to-end to the carotid arteries, with proximal stump ligation. Secondly, with the patient in right lateral recumbency, a left posterolateral thoracotomy exposed the descending aorta. The proximal side of a bifurcated 18-mm 10-mm Hemashield Gold vascular prosthesis (Atrium Medical Co, Hudson, NH) was anastomosed to the descending aorta. One graft distal limb was anastomosed end-to-side to the debranching graft adjacent to the left subclavian artery anastomosis site through the thoracic cavity and subcutaneous route. The other distal limb served as an access route for a Gore TAG Thoracic Endoprosthesis (W. L. Gore & Associates). Two stent grafts were deployed from the ascending to descending aorta. The neck branches and coronary bypass grafts were perfused through one conduit from the descending aorta. Brain saturation by INVOS 5100C System cerebral oximetry (Covidien, Boulder, Colo) showed no marked changes perioperatively. Postoperative computed tomography angiography showed patent debranching bypasses and no abnormal stent graft findings (C/Cover). The patient was followed up as an outpatient. DISCUSSION Shimizu et al1 used the same method for an ascending aorta anastomotic pseudoaneurysm with excellent results. Zhou et al2 and Younes et al3 From the Department of Cardiovascular Surgery, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Kanagawaa; and the Department of Cardiovascular Surgery, Keio University, Shinjuku-ku, Tokyo.b Author conflict of interest: none. E-mail: [email protected]. The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. J Vasc Surg 2016;63:527-8 0741-5214 Copyright Ó 2016 by the Society for Vascular Surgery. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jvs.2014.10.095
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528 Iida et al
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described the same experience from one high-volume center. In this method, delivery of sufficient blood flow from one graft to the supra-aortic vessels and bilateral internal thoracic arteries is crucial. Our echocardiography showed no wall motion changes. Doppler ultrasound showed favorable brain blood flow. For patients at high risk of sternotomy with hypothermic circulatory arrest and unsuitable femoral access for TEVAR, debranching TEVAR from the descending aorta to the supra-aortic vessels is promising. We thank Naoyuki Inagaki for assistance with computed tomography angiography imaging. We are also indebted to Associate Professor Edward Barroga, Senior Medical Editor of Tokyo Medical University, for reviewing and editing the manuscript. REFERENCES 1. Shimizu H, Hachiya T, Yamabe K, Yozu R. Hybrid arch repair including supra-aortic debranching on the descending aorta. Ann Thorac Surg 2011;92: 2266-8. 2. Zhou W, Reardon M, Peden EK, Lin PH, Lumsden AB. Hybrid approach to complex thoracic aortic aneurysms in high-risk patients: surgical challenges and clinical outcomes. J Vasc Surg 2006;44:688-93. 3. Younes HK, Davies MG, Bismuth J, Naoum JJ, Peden EK, Reardon MJ, et al. Hybrid thoracic endovascular aortic repair: pushing the envelope. J Vasc Surg 2010;51:259-66. Submitted Jan 13, 2014; accepted Oct 23, 2014.
Total debranching thoracic endovascular aortic arch repair with inflow from the descending thoracic aorta Yasunori Iida, MD, PhD,a Tsutomu Ito, MD, PhD,a Takahiko Misumi, MD, PhD,a and Hideyuki Shimizu, MD, PhD,b Kanagawa and Tokyo, Japan A 71-year-old man with a 65-mm aortic arch aneurysm was at high risk for open surgery because of previous coronary artery bypass grafting and abdominal prosthetic graft replacement. Two debranching thoracic endovascular aortic repair (TEVAR) with a right subclavian artery inflow was abandoned because computed tomography imaging showed a brachiocephalic artery atherosclerotic lesion (A). The access route showed a strong kinking at the terminal aorta (B). Total debranching TEVAR with descending aorta inflow through left thoracotomy was performed. Firstly, with the patient supine, the arch vessel was debranched using a ringed expanded polytetrafluoroethylene graft (W. L. Gore & Associates, Flagstaff, Ariz) and anastomosed end-to-side to the subclavian arteries and end-to-end to the carotid arteries, with proximal stump ligation. Secondly, with the patient in right lateral recumbency, a left posterolateral thoracotomy exposed the descending aorta. The proximal side of a bifurcated 18-mm 10-mm Hemashield Gold vascular prosthesis (Atrium Medical Co, Hudson, NH) was anastomosed to the descending aorta. One graft distal limb was anastomosed end-to-side to the debranching graft adjacent to the left subclavian artery anastomosis site through the thoracic cavity and subcutaneous route. The other distal limb served as an access route for a Gore TAG Thoracic Endoprosthesis (W. L. Gore & Associates). Two stent grafts were deployed from the ascending to descending aorta. The neck branches and coronary bypass grafts were perfused through one conduit from the descending aorta. Brain saturation by INVOS 5100C System cerebral oximetry (Covidien, Boulder, Colo) showed no marked changes perioperatively. Postoperative computed tomography angiography showed patent debranching bypasses and no abnormal stent graft findings (C/Cover). The patient was followed up as an outpatient. DISCUSSION Shimizu et al1 used the same method for an ascending aorta anastomotic pseudoaneurysm with excellent results. Zhou et al2 and Younes et al3 From the Department of Cardiovascular Surgery, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Kanagawaa; and the Department of Cardiovascular Surgery, Keio University, Shinjuku-ku, Tokyo.b Author conflict of interest: none. E-mail: [email protected]. The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. J Vasc Surg 2016;63:527-8 0741-5214 Copyright Ó 2016 by the Society for Vascular Surgery. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jvs.2014.10.095
527
528 Iida et al
JOURNAL OF VASCULAR SURGERY February 2016
described the same experience from one high-volume center. In this method, delivery of sufficient blood flow from one graft to the supra-aortic vessels and bilateral internal thoracic arteries is crucial. Our echocardiography showed no wall motion changes. Doppler ultrasound showed favorable brain blood flow. For patients at high risk of sternotomy with hypothermic circulatory arrest and unsuitable femoral access for TEVAR, debranching TEVAR from the descending aorta to the supra-aortic vessels is promising. We thank Naoyuki Inagaki for assistance with computed tomography angiography imaging. We are also indebted to Associate Professor Edward Barroga, Senior Medical Editor of Tokyo Medical University, for reviewing and editing the manuscript. REFERENCES 1. Shimizu H, Hachiya T, Yamabe K, Yozu R. Hybrid arch repair including supra-aortic debranching on the descending aorta. Ann Thorac Surg 2011;92: 2266-8. 2. Zhou W, Reardon M, Peden EK, Lin PH, Lumsden AB. Hybrid approach to complex thoracic aortic aneurysms in high-risk patients: surgical challenges and clinical outcomes. J Vasc Surg 2006;44:688-93. 3. Younes HK, Davies MG, Bismuth J, Naoum JJ, Peden EK, Reardon MJ, et al. Hybrid thoracic endovascular aortic repair: pushing the envelope. J Vasc Surg 2010;51:259-66. Submitted Jan 13, 2014; accepted Oct 23, 2014.
