Hybrid debranching and TEVAR of the aortic arch off-pump, in re-do patients with complicated chronic type-A aortic dissections: a critical report

Klaus Brechtel,Stephen M Wildhirt,Günay Kalender,Ulrich A Stock

doi:10.1186/1749-8090-8-188

Klaus Brechtel, Stephen M Wildhirt + Show 2 more

Open Access

https://doi.org/10.1186/1749-8090-8-188

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Abstract

BackgroundPatients suffering from acute type A aortic dissection undergo replacement of the ascending aorta, the proximal hemiarch or complete aortic arch, depending on the extent of the individual pathology. In a subset of these treated patients, secondary pathologies of the distal anastomosis or the remaining distal part of the aorta occur. The treatment of these pathologies is challenging, requiring major surgical re-do procedures with aortic arch replacement under extracorporeal circulation and hypothermic circulatory arrest.MethodsWe report our experience of five patients with complex aortic pathologies after previous aortic surgery treated with a single stage re-do hybrid procedure, consisting of bypass grafting of the supraaortic branches off-pump, stent graft placement for endovascular aortic repair (TEVAR) and surgical debranching of the aortic arch.ResultsIn all patients the surgical vascular grafts and stent grafts were deployed successfully, there were no intraoperative deaths. Four out of five patients were discharged from hospital in good clinical condition. One patient died postoperatively due to cardiac tamponade. In one patient a type I endoleak persisted leading to occlusion of a bypass branch requiring surgical revision at one year after debranching.ConclusionWe discuss the prerequisites, all steps and potential pitfalls of this hybrid aortic arch replacement. The current procedure avoids cardiopulmonary bypass and circulatory arrest, which may benefit early patient outcome; however, patient and device selection plays a key role for immediate success and midterm outcomes. In addition, precise procedural planning and development of customized stents may help to develop this procedure into a true alternative for conventional aortic arch replacement.

Highlights

Patients suffering from acute type A aortic dissection undergo replacement of the ascending aorta, the proximal hemiarch or complete aortic arch, depending on the extent of the individual pathology
Preoperative status and indications for redo surgery Between August 2010 and April 2011, five patients were identified with a significant pathology of the distal aortic anastomosis
We report our experience of five patients with complex aortic pathologies secondary to previous aortic surgery for type-A acute aortic dissection

Summary

Introduction

Patients suffering from acute type A aortic dissection undergo replacement of the ascending aorta, the proximal hemiarch or complete aortic arch, depending on the extent of the individual pathology. In a subset of these treated patients, secondary pathologies of the distal anastomosis or the remaining distal part of the aorta occur The treatment of these pathologies is challenging, requiring major surgical re-do procedures with aortic arch replacement under extracorporeal circulation and hypothermic circulatory arrest. Typical procedure related complications are pseudoaneurysms or development of true aneurysms at the proximal or distal sutureline and re-dissections These problems have been repeatedly reported with the use of various surgical techniques including the use of glue or Teflon-felt reinforcement of the suture lines [5,6]. These pathologies may occur at both, the proximal and/or distal anastomosis of aortic replacement, the present report focuses on distal aortic pathologies

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