Abstract
Classic open ascending aortic replacement is an effective treatment for Stanford type A aortic dissection However it is associated with a mortality ranging between 15 to 60%. This incidence is even higher in recurrent cases. In these patients, hybrid procedures which combine thoracic endovascular aortic repair (TEVAR) with aortic arch vessel bypasses are successfully adopted. This paper reports a successful hybrid management of aortic arch pseudoaneurysm in a 66 year old female patient known to be hypertensive, diabetic,smoker dyslipidemic on dialysis and who underwent one year previously a surgical ascending aortic repair. Aortic arch vessel bypasses -necessary in this case – were facilitated by the presence of an aberrant right subclavian artery known as Arteria Lusoria- This variant, a rare embryologic anomaly of the aortic arch vessels, described by Hunauld in 1735, was used as an inflow artery to the right common carotid allowing the surgeons to avoid a left to right common carotid artery bypass known to be associated with many complications. Although the hybrid management seems a feasible and safe option especially in high risk patients not eligible for open surgical repair, furher clinical studies and development of new devices dedicated to treat ascending aortic diseases are fundamental to improve outcomes.
Highlights
A 66 years old female is admitted to our emergency department with a four days history of chest pain high blood pressure resistant to her medications and a 10 cm pulsatile midline neck mass covering the sternoclavicular junction and the manubrium
In 2000 Dorros et al reported the first case of type A aortic dissection managed with en endovascular technique through a transseptal approach [3], while Metcalfe et al described a case of endovascular repair of an acute type A dissection using an endograft designed for the ascending aorta introduced through the common femoral artery [5]
The brachiocephalic trunk is absent and four large arteries rise from the arch of the aorta:Right common carotid artery, left common carotid artery, left subclavian artery and aberrant right subclavian artery known as Arteria Lusoria and which is the most distal left sided origin [8]
Summary
The patient is known to be hypertensive, diabetic, dyslipidemic and smoker (70py) She has an end stage kidney disease and is on dialysis. Throughout the first year postoperatively, the patient was admitted three times to the emergency room with chest pain and high blood pressure. CT scan of the chest revealed no new changes and the patient was discharged after controlling her blood pressure. Stent graft was inserted through the exposed left femoral artery and inserted across the pseudoaneurysm. The stent graft was placed proximally inside the previous ascending aortic dacron graft and distally before the insertion of the left subclavian artery. At the end of the procedure, the patient was transferred to the coronary surgical unit (CSU) She was extubated the day after dialysis. Two separate teams worked simultaneously to perform a left subclavian to left carotid bypass and a right subclavian to right carotid bypass using 9mm gortex grafts
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