RESUMO
Traditional repair of aortic arch aneurysms requires cardiopulmonary bypass and a period of profound hypothermia and circulatory arrest - allowing detachment of the head vessels off the aneurysm; and their anastomosis onto the graft. The procedure is safe and reproducible; however morbidity is significant and includes air embolism; stroke; excessive bleeding and acidosis. In addition the procedures are time-consuming; and cardioplegic arrest is also necessary; resulting in the potential for low cardiac output. Aortic arch aneurysms are not typically suitable for With improving techniques of descending aortic repair with stent grafts; hybrid techniques; which involve aortic arch debranching - thereby creating a proximal landing zone of adequate length; followed by stenting over the aortic arch are becoming popular. Methods: Four cases are presented. The technique involves initial sternotomy or upper sternal split; detachment of the innominate and left common carotid arteries; and their reattachment to the ascending aorta by separate grafts (debranching procedure). During this time a side clamp is placed on the ascending aorta. The left subclavian is usually left intact for technical reasons; unless there is a dominant left vertebral artery. This is safe as the shoulder has adequate collateral circulation; and stenting over this vessel is therefore well tolerated. The aortic arch is then completely covered with a stent graft which is inserted via the femoral artery. Arteriography was performed at the end of the procedure to confirm stent graft position and exclusion of the lesion. Results: All surgical transpositions were successful; and the patients recovered without neurologic; bleeding or cardiac complications. Surgical conversion for aortic graft was never required. There were no endoleaks. Mean duration of follow up was 53.5 months (range 21-77). Conclusions: Endovascular repair of the descending thoracic aorta; initially reserved for inoperable patients; is now becoming the accepted initial management. With improved technology and endografts it is now the safest option; especially for traumatic dissection. These techniques have now extended to the aortic arch. Debranching of the aortic avoiding cardiopulmonary bypass and circulatory arrest. Good pre-operative planning is necessary to make the procedure feasible