Ann Thorac Surg 2000;70:1974-1976
© 2000 The Society of Thoracic Surgeons
Original article: cardiovascular
Distal arch aneurysm repair using stent-grafting and ascending aorto-left axillary bypass
Yukinori Moriyama, MDa,
Yoshifumi Iguro, MDa,
Koichi Hisatomi, MDa,
Riichiro Toda, MDa,
Goichi Yotsumoto, MDa
a Second Department of Surgery, Kagoshima University, Faculty of Medicine, Kagoshima, Japan
Accepted for publication May 12, 2000.
Address reprint requests to Dr Moriyama, Division of Cardiovascular Surgery, National Takasaki Hospital, Takamatsu-cho 36, Gunma, Japan
e-mail: moriyamy{at}takasaki.hosp.go.jp
 |
Abstract
|
|---|
Background. Transcatheter application of a stent-graft to the angulated aortic segments with critical side branches poses some problems. We report our technique of distal arch aneurysm repairs using stent-grafts inserted through the aortic arch and ascending aorto-axillary bypass.
Patients and Results. Three patients underwent successful distal arch aneurysm repair using a homemade semiflexible stent-graft placed under hypothermic circulatory arrest. The left subclavian artery was reconstructed by an extraanatomic bypass grafting between the ascending aorta and left axillary artery. Postoperative imaging demonstrated reduction of aneurysm size and no endoleaks from an intercostal artery.
Conclusions. Our technique seems to be useful for repair of distal arch aneurysms and is a less invasive procedure.
|
Introduction
|
|---|
Endovascular stent-graft repair offers a new approach to treatment of patients with descending thoracic aortic aneurysms [1]. However, transcatheter application of this device to angulated aortic segments with critical side branches such as aortic arch poses some problems because of the straight and inflexible property of the stent and imprecise deployment maneuvers [2, 3]. We report our experience of distal arch aneurysm repairs using a homemade stent-graft inserted antegrade through the proximal aorta and ascending aorto-axillary bypass to reconstruct the left subclavian artery.
|
Patients and methods
|
|---|
There were 2 men and 1 woman, ranging in age from 68 to 75 years. They all had atherosclerotic aneurysms involving the orifices of the left subclavian arteries (Fig 1A). Their clinical characteristics are shown in Table 1.
View larger version (79K):
[in this window]
[in a new window]
|
Fig 1. Preoperative and postoperative imaging study (patient 3). Preoperative aortography (A) revealed a saccular aneurysm in the distal aortic arch (arrows). Postoperative aortography (B) and computed tomography (CT) (C) taken 2 weeks after the repair demonstrated complete obliteration of aneurysm filling and extraanatomic bypass graft between the ascending aorta and the left subclavian artery (arrows). Follow-up CT (D) taken 4 months after the repair demonstrated reduction of aneurysm size and no endoleaks from intercostal artery.
|
|
A median sternotomy incision was made, and the pericardium was opened. By gentle palpation and epiaortic echocardiography the presence of calcified or atheromatous lesions were detected for cannulation or placement of a side clamp on the ascending aorta. Pulmonary artery catheter and probe to monitor transesophageal echocardiography were used. Esophageal and rectal temperatures were also monitored. The left axillary artery was exposed between the pectoralis major and deltoid muscle above the anterior axillary fold. After heparinization, an 8-mm collagen-impregnated, woven Dacron graft (Meadox Medicals, Inc, Oakland, NJ) was anastomosed to the axillary artery. The left pleura was opened, and a wide hole was created in the first or second intercostal space adjacent to the anastomotic site. The graft was brought down through this hole and anastomosed to the ascending aorta afterward to reconstruct the left subclavian artery. Cardiopulmonary bypass was commenced after venous drainage from the right atrium and arterial return to the ascending aorta. A left ventricular vent was inserted through the right superior pulmonary vein. When the esophageal temperature reached 20°C circulatory arrest was introduced with blood cardioplegia given in a retrograde fashion. A stent-graft was constructed from a self-expanding Gianturco stainless-steel Z stent (Cook, Inc, Bloomington, IN) and a thin-walled woven Dacron vascular graft (Ubekosan, Inc, Ube, Japan). A middle segment of the prosthesis was free of stent to maintain its flexibility to be tailored to the curvature of the distal aortic arch.
The prosthesis was introduced into an applicator, which was prepared from a syringe with the tip of its outer barrel cut (Figure 2). After introduction of circulatory arrest the aortic arch was opened transversely at the origin of the left subclavian artery. The prosthesis was deployed excluding the aneurysm under the guide of transesophageal echocardiography. The proximal end of the stent-graft was fixed to the aorta circumferentially using 4-0 Prolene running suture (Ethicon, Somerville, NJ) just proximal to the orifice of the left subclavian artery, which was obliterated at its origin by ligation. The aortic incision was closed while perfusing through both the femoral artery and ascending aorta to expel air and atheromatous plaques. During the rewarming period an extraanatomic bypass grafting was made between the ascending aorta and the Dacron graft initially attached to the left axillary artery to reconstruct the left subclavian artery.
View larger version (119K):
[in this window]
[in a new window]
|
Fig 2. Semiflexible stent-graft and applicator. A middle segment of the prosthetic graft was free of stent to maintain its flexibility to fit the curvature of the distal aortic arch (A). The stent-graft was introduced into an applicator prepared from a syringe with the tip of its outer barrel cut (B).
|
|
|
Results
|
|---|
All three patients had successful repairs, and proper position and wide expansion of the stent were confirmed with computed tomography (CT) and aortography (Fig 1B, 1C). The patients were discharged from the hospital with no complications and were doing well. Mean cardiopulmonary bypass and circulatory arrest times were 119 and 23 minutes, respectively. Postoperative blood loss ranged from 205 to 360 mL (mean 281 ± 68 mL). Follow-up CT taken 4 months after the repair demonstrated reduction of aneurysm size and no endoleaks from intercostal artery (Fig 1D).
|
Comment
|
|---|
For transcatheter stent-grafting to distal arch aneurysms, the relatively imprecise deployment maneuvers require ample proximal landing zones and expose the left subclavian artery at risk for stent-graft coverage. Mitchell [4] reported a carotid subclavian bypass to be placed before the transcatheter approach so that the stent could be anchored across the origin of the subclavian artery. Our treatment policy for this type of aneurysm is that a no-touch technique is maintained on the atherosclerotic aorta and aneurysm with mural thrombus until hypothermic circulatory arrest is induced to avoid embolic events including stroke [5]. A transverse incision is placed on the aorta to afford complete attachment sites of the stent-graft. The worrisome, unresolved problem with stent-graft repair of aneurysm is the endoleak phenomenon [1, 4]. The potential of endoleaks leading to continued aortic expansion is clear. To cope with this serious concern the proximal end of the stent-grafts is fixed to the aortic wall, taking care not to limit the expanding force of the stent. In such cases there is some difficulty in securing enough room for in situ reconstruction of the left subclavian artery, which is involved because of the aneurysm. Hence, we apply an extraanatomic reconstruction of the left subclavian artery using ascending aortoaxillary bypass.
A homemade semiflexible stent-graft and a large caliber applicator prepared from a syringe was used for the purpose of accurate deployment [6]. To date we have used this device in 6 patients with aortic arch disease with good outcomes. This method has been effective and we have not encountered any complications related to the device itself. In view of our favorable outcome we recommend using this technique for distal arch aneurysms repair particularly in patients at high risk for conventional open surgical procedure.
|
References
|
|---|
-
Dake M.D., Miller D.C., Mitchell R.S., Semba C.P., Moore K.A., Sakai T. The "first generation" of endovascular stent-grafts for patients with aneurysms of the descending thoracic aorta. J Thorac Cardiovasc Surg 1998;116:689-704.[Abstract/Free Full Text]
-
Inoue K., Iwase T., Sato M., et al. Transluminal endovascular branched graft placement for a pseudoaneurysm: reconstruction of the descending thoracic aorta including the celiac axis. J Thorac Cardiovasc Surg 1997;114:859-861.[Free Full Text]
-
Kato M., Ohnishi K., Kaneko M., et al. New graft-implanting method for thoracic aortic aneurysm or dissection with a stented graft. Circulation 1996;94(Suppl II):II188-II193.
-
Mitchell R.S. Endovascular stent graft repair of thoracic aortic aneurysms. Semin Thorac Cardiovasc Surg 1997;9:257-268.[Medline]
-
Westaby S., Katsumata T. Proximal aortic perfusion for complex arch and descending aortic disease. J Thorac Cardiovasc Surg 1998;115:162-167.[Abstract/Free Full Text]
-
Moriyama Y., Iguro Y., Watanabe S., Yotsumoto G., Yamamoto H. Endovascular stent-grafting for redo aortic surgery using an applicator prepared from syringe, and flexible stent-graft. J Thorac Cardiovasc Surg 2000;119:620-621.[Free Full Text]
Top
Abstract
Introduction
