Endovascular Aortic Arch Reconstruction with Supra-Aortic Transposition for Symptomatic Contained Rupture and Dissection: Early Experience in 8 High-Risk Patients

Abstract

Purpose:

To report our initial experience with total and subtotal endovascular aortic arch reconstruction combined with supra-aortic vessel transposition in high-risk patients and to present a new morphological classification of thoracic aortic lesions for patient and procedure selection.

Methods:

Among 80 patients treated with thoracic stent-grafts at our department between 1997 and 2003, 8 patients (6 men; mean age 71 years, range 45–81) unfit for open repair were not candidates for standard endovascular repair due to inadequate proximal landing zones on the aortic arch. Commercially available endografts (Excluder, Zenith, Endofit, Talent) were used to repair the arch after supra-aortic vessel transposition was performed. The endograft was implanted transfemorally or via an iliac Dacron conduit graft with standardized endovascular techniques and deployed during intravenous adenosine-induced asystole. The imaging data from all thoracic endograft patients was analyzed to classify thoracic and thoracoabdominal lesions according to a 4-level anatomical system.

Results:

Deployment success was 100% after staged supra-aortic vessel transposition, but 1 patient died of endograft-related rupture of the proximal aortic arch. There was no neurological complication. Mean follow-up was 16 months (range 1–36). Patency of all endografts and conventional bypasses was 100%, and no migration was observed. One minor type II endoleak was demonstrated.

Conclusions:

Initial results are encouraging for endovascular aortic arch repair in combination with supra-aortic transposition in selected high-risk patients with complex aortic pathologies.

Keywords

thoracic aortic aneurysm aortic arch dissection contained rupture vessel transposition endovascular repair stent-graft

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References

Burks

Faries

Gravereaux

. Endovascular repair of thoracic aortic aneurysms: Stent-graft fixation across the aortic arch vessels. Ann Vasc Surg. 2002; 16: 24–28.

Criado

Barnatan

Rizk

. Technical strategies to expand stent-graft applicability in the aortic arch and proximal descending thoracic aorta. J Endovasc Ther. 2002; 9(suppl II): II-32–II-38.

Dake

Miller

Mitchell

. The “first generation” of endovascular stent-grafts for patients with aneurysms of the descending thoracic aorta. J Thorac Cardiovasc Surg. 1998; 116: 689–704.

Grabenwoger

Fleck

Czerny

. Endovascular stent graft placement in patients with acute thoracic aortic syndromes. Eur J Cardiothorac Surg. 2003; 23: 788–793.

Mitchell

. Stent grafts for the thoracic aorta: A new paradigm? Ann Thorac Surg. 2002; 74: S1818–1820.

Kahn

Moskowitz

Marin

. Safety and efficacy of high-dose adenosine-induced asystole during endovascular AAA repair. J Endovasc Ther. 2000; 7: 292–296.

Hayashi

Eguchi

Yasuda

. Aortic arch operation using selective cerebral perfusion for nondissecting thoracic aneurysm. Ann Thorac Surg. 1997; 63: 88–92.

Nakai

Shimamoto

Yamazaki

. Long-term results after surgery for aortic arch nondissection aneurysm [in Japanese]. Kyobu Geka. 2002; 55: 280–284.

Schepens

Dossche

Morshuis

. The elephant trunk technique: Operative results in 100 consecutive patients. Eur J Cardiothorac Surg. 2002; 21: 276–281.

10.

Kazui

Yamashita

Washiyama

. Usefulness of antegrade elective cerebral perfusion during aortic arch operations. Ann Thorac Surg. 2002; 74: S1806–1809.

11.

Spielvogel

Strauch

Minanov

. Aortic arch replacement using a trifurcated graft and selective cerebral antegrade perfusion. Ann Thorac Surg. 2002; 74: S1810–1814.

12.

Inoue

Hosokawa

Iwase

. Aortic arch reconstruction by transluminally placed endovascular branched stent graft. Circulation. 1999; 100(Suppl 19): II316–II321.

13.

Görich

Asquan

Seifarth

. Initial experience with intentional stent-graft coverage of the subclavian artery during endovascular thoracic aortic repairs. J Endovasc Ther. 2002; 9(suppl II): II-39–II-43.

14.

Pamler

Kotsis

Görich

. Complications after endovascular repair of type B aortic dissection. J Endovasc Ther. 2002; 9: 822–828.

15.

Diethrich

. Commentary: A safe, simple alternative for pressure reduction during aortic endograft deployment. J Endovasc Surg. 1996; 3: 275.

16.

Baker

Bookallil

Lloyd

. Intentional systole during endoluminal thoracic aortic surgery without cardiopulmonary bypass. Br J Anaesth. 1997; 78: 444–448.

17.

Kahn

Marin

Hollier

. Induction of ventricular fibrillation to facilitate endovascular stent graft repair of thoracic aortic aneurysms. Anesthesiology. 1998; 88: 534–536.

18.

Marty

Chapuis

Tozzi

. Inflow occlusion provides accurate deployment in thoracic aortic endografting [Abstract]. J Endovasc Ther. 2003; 10(Suppl): I-28.

19.

Weigand

Motsch

Bardenheuer

. Adenosine-induced transient cardiac arrest for placement of endovascular stent-grafts in the thoracic aorta. Anesthesiology. 1998; 89: 1037–1038.

20.

Yasuda

Tateoka

Sakurai

. Anesthetic management of endovascular stent-graft placement for thoracic aortic aneurysm using induction of transient cardiac asystole by ATP [in Japanese]. Masui. 2002; 51: 1023–1025.

21.

Dorros

Cohn

. Adenosine-induced transient cardiac asystole enhances precise deployment of stent-grafts in the thoracic or abdominal aorta. J Endovasc Surg. 1996; 3: 270–272.

22.

Rudolphi

Keil

Hinze

. Effect of theophylline on ischemically induced hippocampal damage in Mongolian gerbils: A behavioral and histopathological study. J Cereb Blood Flow Metab. 1987; 7: 74–81.

23.

White

. Commentary: Transient asystole for aortic endograft deployment: A technique justified only in highly selected cases. J Endovasc Surg. 1996; 3: 273–274.

24.

Ely

Berne

. Protective effects of adenosine in myocardial ischemia. Circulation. 1992; 85: 893–904.

25.

Adams

Heyer

Emerson

. Implantable cardioverter-defibrillator. Evaluation of clinical neurological outcome and electroencephalographic changes during implantation. J Cardiovasc Surg. 1995; 109: 565–573.

26.

Lepore

Lönn

Delle

. Endograft therapy for diseases of the descending thoracic aorta: Results in 43 high-risk patients. J Endovasc Ther. 2002; 9: 829–837.

27.

Orihashi

Sueda

Watari

. Endovascular stent-grafting via the aortic arch for distal aortic arch aneurysm: An alternative to endovascular stent-grafting. Eur J Cardiothorac Surg. 2001; 20: 973–978.