Complete Endovascular Arch Reconstruction With a Multibranch Device for the Management of Aortic Arch Aneurysm

Abstract

Open surgical repair through median sternotomy remains the standard of care for aortic arch aneurysms; however, such operative approach is associated with significant morbidity and mortality. New endovascular technology now allows us to treat those patients who are poor candidates for open surgical repair. The patient is a 57-year-old man who we have been observing for an expanding aortic arch aneurysm. During the last 3 years, this has grown in size from 53 to 64 mm. Given his multiple cardiac and pulmonary comorbidities, our cardiothoracic colleagues have deemed him a poor candidate for open repair. Based on radiologic imaging, he was found to have appropriate anatomy for a branched endovascular reconstruction. The operation was performed in collaboration with the cardiothoracic surgery team. At the start of our operation, a left-sided carotid-subclavian arterial bypass was created. Open access to the right carotid and left femoral arteries was also employed. The main thoracic endograft, incorporating two internal branches, was delivered from the femoral artery and deployed in zone 0 under rapid ventricular pacing. The internal branches were cannulated from the left and right common carotid arteries. Self-expanding covered stent grafts were deployed into the internal branches, extending to the innominate and left common carotid arteries. The proximal left subclavian artery was occluded with an endovascular plug. He was discharged home in stable condition on postoperative day 7. Follow-up outpatient imaging revealed an intact repair with no endoleak. Branched endovascular technology will allow us to treat aortic arch disease not readily amenable to open surgical repair. Early experience with multibranch endovascular arch devices is promising.