Hybrid aortic repair with antegrade supra-aortic and renovisceral debranching from ascending aorta

Abstract

Aortic dissection is a life threatening condition. Hybrid repair has been described for the treatment of complex aortic pathology such as thoracoabdominal aortic aneurysms (TAAA) and type A and B dissections, although open and total endovascular repair are also possible. Open surgery is still associated with substantial perioperative morbi-mortality rates, thus less invasive techniques such as endovascular repair and hybrid procedures can achieve good results in centers with experience. We present the case of a patient with a chronic type B dissection and TAAA degeneration that was treated in a single stage hybrid procedure with antegrade supra-aortic and renovisceral debranching from the ascending aorta and TEVAR. At threeyear follow up, the patient is free of intervention-related complications. J Thorac Dis 2017;9(Suppl 6):S539-S543 jtd.amegroups.com and 94% at 28 months, 6 and 8 years, have been reported with this procedure (6-9). A three-year estimated survival rate of 83%; freedom of type I endoleak and reintervention of 100% and 78%, respectively, have been also reported (10). A similar technique was previously described by Torsello et al., using three bifurcated Dacron grafts for an antegrade thoracic and renovisceral debranching (11). Case presentationA 68-year-old female was admitted to the Emergency Department due to severe back and chest pain with concomitant loss of consciousness. Her clinical records showed a past medical history of hypertension, Paget's disease, cholecystectomy, appendectomy and a known chronic type B aortic dissection that was under follow-up at another center. The emergency angio-CT (computed tomography), showed a 6 cmc TAAA, due to a chronic type B dissection with involvement from Zone 0 of the aortic arch, extending to the right common iliac artery and to the left hypogastric artery. The celiac trunk and the right renal artery were also dissected, with all the renovisceral vessels arising from the true lumen.Initially the patient was transferred to the intensive care unit (ICU) for monitoring and blood pressure control. Seventy-two hours later, surgical treatment was decided because of the persistence of symptoms and difficult blood pressure control. An antegrade supra-aortic and renovisceral debranching was decided from ascending aorta due to extensive aortic disease with significant calcification at the renovisceral level and taking into account that the infrarenal aorta and both iliac arteries were not suitable as inflow sites. Under general anaesthesia and with cerebrospinal fluid (CSF) drainage, a median sternotomy was performed, allowing control of the ascending aorta and supra-aortic vessels. With tangential aortic clamping a 16×8 mm bifurcated Dacron graft was sutured to the ascending aorta with downward orientation of its limbs (Figure 1). From the main body of this bifurcated graft, a 10mm Dacron tube was used to debranch the brachiocephalic trunk performing a distal termino-terminal anastomosis. A 8mm Dacron graft was used to create a Y shaped graft, which ...

Follow-up Results of Endovascular Aneurysm Repair Following Abdominal Visceral Debranching

“…Hybrid techniques preceded by debranching procedures are considered as one of the solutions in especially elderly patients or patients with comorbidities — complex and extensive pathologies [ 1 ] . The technique has been also used in the treatment of Types A and B dissections to enable new convenient landing zones for endovascular repair with debranching of branches of aortic arch and visceral arteries [ 3 ] . It is especially beneficial in emergency cases who have challenging anatomies and are not appropriate for sole endovascular procedures due to anatomical limitations [ 1 ] .…”