Elsevier

The Annals of Thoracic Surgery

Volume 88, Issue 6, December 2009, Pages 1882-1888
The Annals of Thoracic Surgery

Original article
Adult cardiac
“Hybrid” Repair of Aneurysms of the Transverse Aortic Arch: Midterm Results

Presented at the Fifty-fifth Annual Meeting of the Southern Thoracic Surgical Association, Austin, TX, Nov 5–8, 2008.
https://doi.org/10.1016/j.athoracsur.2009.07.027Get rights and content

Background

Aneurysms of the transverse aortic arch, especially those involving the mid to distal arch, are technically challenging to repair with conventional open techniques. We present our results with a combined open/endovascular approach (“hybrid repair”) in such patients.

Methods

From August 11, 2005, to September 18, 2008, 28 patients underwent hybrid arch repair. For patients (n = 9) with distal arch aneurysms but 2 cm or more of proximal landing zone (PLZ) distal to the innominate artery, right to left carotid-carotid bypass was performed to create a PLZ by covering the left carotid origin. For patients (n = 12) with mid arch aneurysms but 2 cm or more of PLZ in the ascending aorta, proximal ascending aorta-based arch debranching was performed. For patients (n = 7) with arch aneurysms with no adequate PLZ (“mega aorta”) but adequate distal landing zone, a stage 1 elephant trunk procedure was performed to create a PLZ. For the first two groups, endovascular aneurysm exclusion and debranching were performed concomitantly, whereas the procedures were staged for the group undergoing an initial elephant trunk procedure.

Results

Mean patient age was 64 ± 13 years. Primary technical success rate was 100%. Thirty-day/in-hospital rates of death, stroke, and permanent paraplegia/paresis were 0%, 0%, and 3.6% (n = 1), respectively. At a mean follow-up of 14 ± 11 months, there have been no late aortic-related events. Two patients (7%) required secondary endovascular reintervention for a type 1 endovascular leak. No patient has a type 1 or 3 endovascular leak at latest follow-up.

Conclusions

Hybrid repair of transverse aortic arch aneurysms appears safe and effective at midterm follow-up and may represent a technical advance in the treatment of this pathology.

Section snippets

Patients and Methods

Between March 23, 2005 (date of Food and Drug Administration approval of the first available thoracic device in the United States) and October 23, 2008, 178 thoracic endograft procedures were performed at our institution. Of these, 28 (16%) were hybrid arch repairs (performed between August 11, 2005 and September 18, 2008) and form the basis of this report. Indications for surgery included either saccular (n = 11) or fusiform (n = 17) aneurysms of the transverse arch. In 10 patients (36%), the

Patient Demographics

Mean aneurysm diameter was 6.1 ± 1.6 cm (range, 3.1 to 11.0 cm). Patient demographics are presented in Table 1. Eleven (39%) had undergone prior open aortic surgery, including prior ascending aortic replacement for type A dissection in 6 (21%). The distal extent of aortic coverage by the endografts was above T6 in 18 (64%) and below T6 in 10 (36%). Thirteen (46%) of the patients were symptomatic with pain symptoms; 21% (6 of 28) of the cases were urgent (aneurysm repaired during the same

Comment

Aneurysms of the transverse aortic arch, especially those involving the mid to distal arch, are technically challenging to repair with conventional open techniques. These challenges relate to difficulties with exposure, need for deep hypothermic circulatory arrest, and frequent requirement for a two-stage approach to complete repair. Total arch replacement, although now performed routinely and safely in centers with expertise, still carries a perioperative death or stroke rate approaching 15%,

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    Citation Excerpt :

    Type I HAR involves head vessel reimplantation (“debranching”) via a multibranched graft (Gelweave Trifurcate Arch Graft; Terumo Aortic) from the ascending aortic Dacron graft placed at the time of index ATAAD repair with subsequent exclusion of the arch pathology via endograft(s) with PLZ in the preexisting Dacron ascending aorta (zone 0; Figure 2); the technique has previously been described in detail (Video 1).18 Although the arch debranching and TEVAR portions of the procedure can be performed concurrently using either antegrade or retrograde endograft delivery, performing these cases in 2 stages during a single hospital stay has evolved as the preferred technique.11,19 Likewise, performing the first-stage arch debranching procedure using beating heart cardiopulmonary bypass (CPB) is now preferred, because this facilitates obtaining very proximal exposure of the existing ascending Dacron graft for the site of the proximal anastomosis of the arch debranching graft and thereby maximizes the potential PLZ for the endografts.18

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Recipient of the 2008 Clifford Van Meter President's Award.

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