Hybrid Aortic Arch Replacement: A Novel Surgical Technique for a Difficult Problem

Ravi De Silva,Stephen Large,Vimal Raj,Simon Messer

doi:10.4236/ss.2011.26071

Abstract

Aneurysms of the aortic arch and descending aorta are invariably fatal if left to expand, but also represent considerable surgical challenges. The development of endovascular stent grafts in combination with aortic debranching has produced results at least comparable to the more traditional surgical approach, but with considerably less comorbidity. We describe a technique for debranching of the aortic arch without the use of circulatory support, and in doing so creating a landing zone for thoracic endovascular aneurysm repair (TE-VAR). Although this procedure has been described, innovative features of our technique include transection of the left hemisternum to produce excellent surgical exposure, and ligation of the debranched arch vessels to prevent Type II endoleaks following TEVAR. Additionally, by not using mechanical circulatory support, we remove the associated pathophysiological insult, inflammatory response, and coagulopathy that is synonymous with cardiopulmonary bypass. There is also no need for circulatory arrest, with its associated perils.

Highlights

Arch and descending aortic aneurysms are complex problems which have traditionally been treated with extensive surgical procedures needing circulatory support, and often a period of circulatory arrest [1,2]
We describe a technique for debranching of the aortic arch without the use of circulatory support, and in doing so creating a landing zone for thoracic endovascular aneurysm repair (TEVAR)
The use of endovascular stents and TEVAR is suitable in some descending aortic aneurysms [4], but in other cases and for arch aneurysms, there is no satisfactory landing zone to anchor the stent, without jeopardizing one or more of the arch vessels

Summary

Introduction

Arch and descending aortic aneurysms are complex problems which have traditionally been treated with extensive surgical procedures needing circulatory support, and often a period of circulatory arrest [1,2]. The use of endovascular stents and TEVAR is suitable in some descending aortic aneurysms [4], but in other cases and for arch aneurysms, there is no satisfactory landing zone to anchor the stent, without jeopardizing one or more of the arch vessels. On occasion this problem can be negotiated by landing the stent between left common carotid and left subclavian arteries. Hybrid (open surgery followed by TEVAR) approaches to arch aneurysms are well reported This is described via a median sternotomy with and without the use of cardiopulmonary bypass [5]. Our technique utilizes a modified sternotomy for better access and ligation of individual native arch vessels to prevent future endoleaks, without mechanical circulatory support

Case Report

Conclusions