One stage hybrid repair of aortic arch aneurysms with antegrade endovascular graft deployment

ABSTRACT

Despite advances in surgical technique and intensive care medicine, the mortality and morbidity of standard single or two staged approaches for the management of arch aortic aneurysms remain extremely high. With the elephant trunk technique, some patients never proceed to completion of treatment either because of worsening co-morbidity or interim rupture. Retrograde thoracic endografting is not always feasible and its complications are well known. This study examines the use of a hybrid approach for treating arch aneurysms in one stage. The technique combines open aortic arch debranching with antegrade stent repair of these aneurysms. In this series three women and nine men with aneurysms involving the arch, ascending and descending thoracic aorta were treated. Their median age was 66 years. Most aneurysms were degenerative in aetiology [50%. The rest were either dissecting or secondary to Marfan's disease. One patient had the ascending aorta replaced prior to presenting with the arch problem. All other patients were put on cardiopulmonary bypass and had their ascending aorta replaced with or without further concomitant cardiac procedures. Cerebral perfusion was maintained antegrade at 24[degree sign] C through right axillary artery cannulation. This was followed by debranching of the arch of aorta and closure of the origins of the innominate, left common carotid and left sub-clavian arteries. The thoracic endografts were then introduced antegrade through a side arm connected to the body of the main aortic graft. No attempt was made to revascularise the left sublcavian artery. All patients were followed-up with CT scans. No patients was lost to follow-up. It was possible to complete the procedure in a single stage in all patients. The mean operative time was 5.7 hours. There was no intraoperative mortality. There were no intra or postoperative coagulation problems. Two patients had immediate type II endoleak that disappeared completely in one month. One patient died postoperatively having developed acute renal failure and chest infection. Acute renal failure requiring temporary dialysis occurred in three other patients. One patient developed delayed paraparesis that recovered with CSF drainage. One patient suffered with lower medial quadranopia in the right eye. There were no strokes or permanent spinal neurological deficits. Two patients with history of COPD required prolonged respiratory support. They were no long term complications secondary to occlusion of the left subclavian artery. The median length of ITU stay was 5.1 days. The mean length of hospital stay was 15.8 days. During a median follow-up duration of 8.8 months two patients were successfully treated for type II endoleak and one patient developed type 1 endoleak that required extension of the bottom end of the endografts. All aortic debranching grafts remain patent to last follow-up. One stage hybrid repair of aneurysms involving the aortic arch is a feasible technique. The preliminary results of this series show low mortality and complications rate. Larger series with longer follow-ups are underway