Branched endovascular repair of aortic arch aneurysm with a modular stent-graft system.

Abstract

A 60-year-old man with new-onset chest and back pain was found at computed tomography to have a 6-cm pseudoaneurysm of the aortic arch at the site of open surgical repair of an arch aneurysm 6 years previously. The history was notable for severe chronic obstructive pulmonary disease, previous coronary artery stenting, and type IV thoracoabdominal aneurysm repair. An arch aortogram showed a wide-necked, saccular pseudoaneurysm of the aortic arch, originating opposite the left common carotid artery (A). Because of poor cardiopulmonary function and previous arch surgery, the patient was considered at prohibitive risk for traditional open aneurysm repair. Endovascular repair of the aortic arch pseudoaneurysm was performed with the patient under general anesthesia, with a branched modular stent-graft device and insertion procedure, described in an accompanying article in this issue of the Journal. The bifurcated stent graft directed all flow from the ascending aorta into the innominate artery and descending thoracic aorta while excluding flow to the aneurysm. Preparatory reconstruction of the brachiocephalic circulation included carotid-carotid bypass grafting, transposition of the left subclavian artery, and implantation of the left vertebral artery into the left subclavian artery. The operation required 6 hours. Completion angiograms revealed proper graft placement, with perfusion of all brachiocephalic arteries and no endoleak (B). These findings were confirmed on postoperative computed tomography scans (C, Cover). Recovery was complicated by a week-long period of ventilatory support and an episode of atrial flutter. There were no cardiac or neurologic complications. The patient was discharged home with warfarin for prophylaxis against cerebral thromboembolism. Conventional repair of aortic arch aneurysm or dissection requires sternotomy and graft replacement, usually with deep hypothermic circulatory arrest, with high morbidity and mortality. Despite the appeal of less invasive techniques, development of an endovascular system has been slowed by site-specific challenges such as the need to maintain uninterrupted cerebral perfusion. We believe that this case illustrates the advantages of a modular approach that combines well-tried stentgraft components and techniques in a new application. The only previously reported case of endovascular arch repair involved deployment of a complicated unibody, branched stent graft. Its successful deployment reflected a level of technical skill that has not been replicated. If our method of aortic arch repair proves both durable and reproducible, potential applications might include not only aneurysms of the arch, but also some type A dissections.