Endovascular Aortic Arch Repair After Aortic Arch De-branching

Abstract

Purpose. Conventional surgical therapy of aortic arch aneurysms consists of aortic arch replacement requiring cardiopulmonary bypass and deep hypothermic circulatory arrest. This method is associated with significant morbidity and mortality, mainly due to neurologic complications and the sequelae of deep hypothermic circulatory arrest. Thus, it makes sense to work on developing less invasive surgical techniques.Description. Surgical aortic arch de-branching is required before the supra-aortic vessels can be safely covered by an endovascular stent graft. We describe how the supra-aortic vessels can best be revascularized, followed by complete coverage of the aortic arch with endovascular stent grafts.Evaluation. We hereby present our case selection criteria, preoperative work-up, and surgical approach for aortic arch de-branching with supra-aortic revascularization, followed by complete coverage of the aortic arch by endovascular stent grafting. This technique's safeguards and pitfalls are described for a cohort of 26 patients. We now describe how the BT and LCCA can best be revascularized, followed by complete coverage of the aortic arch with ESGs. Conclusions. Endovascular aortic arch repair after aortic arch de-branching has Technique PatientsWe performed EVAAR after aortic arch de-branching in 26 patients. We chose the endovascular approach over conventional aortic arch replacement with cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest in selected patients considered at high-risk due to multiple comorbidities and advanced age (Fig 1). Aortic arch pathology consisted of an aneurysm in 15 cases, and 6 patients presented a previous aortic dissection with development of an aortic arch aneurysm. A penetrating ulcer in the aortic arch was the underlying pathology in five cases. The ethics committees approved the study and waived the need for patient consent. Arch Vessel RevascularizationSurgery was initiated with an upper right, L-shaped, hemi-sternotomy to the third or fourth intercostal space. After exposing the ascending aorta, the supraaortic vessels were dissected and the innominate vein was encircled. Then the ascending aorta was tangen-

Aortic arch replacement with prophylactic aortic arch debranching during type A acute aortic dissection repair: initial experience with 23 patients☆

“…However, the limitations of endovascular therapy result from the need of an appropriate landing zone that allows to safely release the stent graft [15]. It is generally accepted that the proximal landing zone should be at least 2 cm proximal to the lesion.…”

Complications after aortic arch hybrid repair

“…14,15,24,26 Reasons include a short landing zone (Ͻ2 cm), which might have been accepted in a first approach (especially emergency cases) to avoid sternotomy and complete debranching in these highrisk patients. In our series, 5/6 proximal type I endoleaks were seen after partial debranching and 4/6 were sealed with further debranching and proximal stent graft extension.…”

The Vienna aneurysm program

“…Additionally, the potential risk of clot formation on the artificial surface of an alloplastic vascular prosthesis is avoided. Nevertheless, several authors have described excellent results with alloplastic reconstructions in this particular subgroup of patients [45][46][47][48]52].…”

“…Due to the novelty of such procedures, few data are available with regard to mid-term and long-term patency rates [45][46][47][48]52]. Our mean follow-up period is 20 months [range 1-54 months].…”